Medical Transportation Grant Application

Section 1: Applicant Information

Section 2: Grant Information

Section 3: Agreement

By submitting this application form, I confirm that:

1. I am a resident of the City of Cold Lake
2. The information provided on this application is true, complete and correct.
3. 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) 

Section 4: Document Checklist

The following documention must accompany this application:

5513 48 Ave., Cold Lake, AB, T9M 1A1, Ph: 780-594-4494, Fax: 780-594-3480

Information on this form is collected for the sole use of the City of Cold Lake and is protected under the authority of the Freedom of Information and Protection of Privacy Act, Sec. 33 (c), which regulates the collection, use and disclosure of personal information. If you have any questions or concerns, please contact the FOIP Coordinator by email (legislative@coldlake.com) or by phone: 780-594-4494, ext. 7915.