Get Application For Special Transportation Subsidy Form

APPLICATION FOR SPECIAL TRANSPORTATION SUBSIDY The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Employment and Assistance Act or the Employment and Assistance for Persons with Disabilities Act. I hereby give permission for the Ministry of Social Development and Social Innovation to confirm the information provided to the Bus Pass Program for the purpose of determining my eligibility and authorize the physician identified in this application to share this personal information with the Ministry of Social Development and Social Innovation. I acknowledge that if I am issued the Special Transportation Subsidy I will be required to surrender my Bus Pass Program eligibility for that fiscal year. The disclosure of this personal information is subject to the provisions of the Freedom of Information and Protection of Privacy Act. Any questions about the collection use or disclosure of this information should be directed to your local Employment and Assistance Office. P LE The Special Transportation Subsidy is provided by the Ministry of Social Development and Social Innovation* To qualify for the Special Transportation Subsidy a person must Have the Persons with Disabilities PWD designation and be in receipt of assistance under the Employment and Assistance for Persons with Disabilities Program Reside in an area where the Bus Pass Program is available Be unable to use the Bus Pass Program or any other form of subsidized public transportation service such as handyDART and Taxi Savers due to their disability or have a disability that would worsen by using public transportation* Forfeit eligibility for the Bus Pass Program* PART A - To be completed by applicant Please Print Applicant s Name Applicant s Address Social Insurance Number 123 123 123 Physician s Name Medical Practictioner Number Phone Number 1. Please describe the applicant s disability. City Postal Code Phone Number Personal Health Number 2. Does this disability prevent the applicant from using public transportation M Bus 2. Do you currently have a bus pass YES NO Taxi Saver 3. How does your disability prevent you from using any form Handy Dart 3. Would the applicant s disability be worsened by using handyDART A 4. How would using public transportation make your disability worse 4. Complete only if the answer to question 2 or 3 is What form of alternative transportation is required to accommodate the applicant s disability S order to accommodate your disability Physician s Signature Date YYYY MMM DD APPLICANT DECLARATION The Information provided above is true to the best of my knowledge. The disclosure of this personal information is subject to the provisions of the Freedom of Information and Protection of Privacy Act. Any questions about the collection use or disclosure of this information should be directed to your local Employment and Assistance Office. Any questions about the collection use or disclosure of this information should be directed to your local Employment and Assistance Office. P LE The Special Transportation Subsidy is provided by the Ministry of Social Development and Social Innovation* To qualify for the Special Transportation Subsidy a person must Have the Persons with Disabilities PWD designation and be in receipt of assistance under the Employment and Assistance for Persons with Disabilities Program Reside in an area where the Bus Pass Program is available Be unable to use the Bus Pass Program or any other form of subsidized public transportation service such as handyDART and Taxi Savers due to their disability or have a disability that would worsen by using public transportation* Forfeit eligibility for the Bus Pass Program* PART A - To be completed by applicant Please Print Applicant s Name Applicant s Address Social Insurance Number 123 123 123 Physician s Name Medical Practictioner Number Phone Number 1.