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Personal Information
* First Name:
Middle Initial:
* Last Name:

Contact Information
* Email Address:
* Phone Number:
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Mailing Address
Non-Canadian residents must apply for a permit in person at a Compliance, Monitoring and Inspections office.
* Address Line 1:
Address Line 2:
* City:
Territory / Province:
* Postal Code:

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Your personal information is being collected under the authority of the 29(c) of the Access to Information and Protection of Privacy Act and will be used for the administration and enforcement of the Act and Regulations, as well as for evaluation, research and statistical purposes.

If you have any questions about the collection, use or disclosure of your personal information, please contact:

Energy, Mines and Resources
Box 2703, Whitehorse, Yukon, Canada, Y1A 2C6
Telephone: 867-667-3111 or toll free in Yukon 1-800-661-0408 extension 3111

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