Required fields are marked with asterisks (*)

Sample Digital Form Template

Please complete this form to apply for this Service. You will be asked a series of questions and to provide information to apply for this Service. We are collecting this information from to determine if you are eligible for the Service. If you need an alternate format or help with filling out this form, please contact the Region at 519-575-4400. We will contact you within 10 business days to let you know if you are eligible for the Service.

Section A

Please provide your name and contact information in this section.

Name

Address 1

Address 2

City or Town

Postal code

Phone number

Section B

Please tell us more about you to determine your eligibility for the service.

Please upload a document that shows your income amount, such as a pay stub or your most recent T4.

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

Please tell us what supports you might need from us.

Answer A

Answer B

Answer C

Answer D

Answer E

Section C

I certify that the answers I provided are to the best of my knowledge.

Please sign the form.

Clear

Date