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Persons With Disabilities Designation Application ...

HR3642 (18/03/26)Page 1 of 2 Persons with Disabilities Designation Application - Prescribed Class Security Classification: MEDIUM SENSITIVITYThe personal information requested on this form is collected by the Ministry of Social Development and Poverty Reduction pursuant to sections 26(c) of the Freedom of Information and Protection of Privacy Act for the purpose of administering the Employment and Assistance for Persons with Disabilities Act. If you have any questions about the collection, use or disclosure of this information, please contact the Ministry of Social Development and Poverty Reduction at 1-866-866-0800.

benefits or supports under the program operated by that agency for the purpose of assessing my eligibility for designation as a Person with Disabilities and for assistance under the Employment and Assistance for Persons with Disabilities Act. Applicant Signature* Date Signed

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