By completing this form, you acknowledge that you are responsible for the completeness and accuracy of the information you provide. Any false or misleading statement with respect to this form and any supporting information required pursuant hereto may result in the denial of your application and refusal of services. All personal information provided on this form is collected by the Town of Hay River for the purpose of determining entitlement of the applicant for the provision of services described herein. In the performance of those services, the personal information is collected, used, and disclosed under the authority of the Access to Information and Protection of Privacy Act and any other provincial laws, regulations, and policies applicable to the protection of personal information. By submitting this form, the applicant consents to the collection, use, and disclosure of personal information by the Town of Hay River for the provision of services. This acknowledgment shall be governed and construed in accordance with the laws of the Northwest Territories.