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Medical Transportation Grant Application

Section 1: Applicant Information

Name:

Property address:

Mailing address (if different than property address)

Email Address:

Phone number:

Date of birth:

Section 2: Grant Information

Have you attended a medical appointment or received service at least 150 kilometers (one way) outside of Cold Lake?

Yes

Are you submitting a claim for an appointment which took place in the last six (6) weeks?

Yes

Have you made an application to this program previously during this same calendar year?

Yes

Section 3: Agreement

By submitting this application form, I confirm that:

I am a resident of the City of Cold Lake
The information provided on this application is true, complete and correct.
I have read, understand and agree to abide by the terms and conditions governing the grant outlined in the Medical Transportation Grant Policy (Policy Number 223-FC-22)

Signature

Clear

DATE:

Section 4: Document Checklist

The following documention must accompany this application:

Confirmation of Medical Appointment

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Proof of Residency

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Most recent CRA Notice of Assessment.

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Information on this form is collected for the sole use of the City of Cold Lake and is protected under the authority of the Protection of Privacy Act, Sec. 4 (c), which regulates the collection, use, and disclosure of personal information.

If you have any questions or concerns, please contact the ATIA Coordinator by email (legislative@coldlake.com) or phone (780) 594-4494 ext. 7915.