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2. 
4. Refund:
6. First Name*
7. Last Name*
9. Email Address*
10. Tax Roll Number*
14. Civic Address*
16. Mailing Address
18. Street Address or P.O. Box*
20. City*
21. Province*
22. Postal Code*
26. Credit Amount*
28. Refund Delivery Method

    1. Pick Up (phone number must be provided)
    2. Mail Out
29. Phone Number
31. Reason For Refund
35. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
37. Electronic Signature*
38. Date*
    Date
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40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field