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Métis Elders and Seniors Assistance Program (MESAP) (WAITLIST)
Name
First Name
Last Name
Mailing Address
Address
Address 2
City/Town
ZIP/Postal Code
Email
Phone
Date of Birth
Citizenship Number
Applying as:
Applying as a Single Applicant $2,500
Applying as a Couple Applicant $4,000
Please describe what health-related equipment or services you are applying for
Annual Household Income
Please upload a copy of your notice of assessment. (If applying as a couple, please upload both Notice of Assessments - applications will not be complete without Notice of Assessments.)
One file only.
200 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.
This funding is only available to Métis citizens, or Métis with an application pending.
I declare that all the information given in this application form is true and complete and that this information is factual and true.
I declare that I am a current MNBC Citizen or have an active application for MNBC citizenship.
Give consent to MNBC and its agents to investigate and disclose any of the facts given in this application form for internal purposes or to other agencies for any of these reasons:
To confirm identity.
To confirm enrollment/registration.
Agree to reimburse MNBC the full amount of funding if they have not made full and accurate disclosure of information.
Acknowledge and agree that the facts given in this application form will be kept and disposed of as required by the Information Management Act.
Agree that MNBC may collect data and contact them from time to time for the purpose of conducting any client-related surveys about Programs.
Understand that this application does not obligate MNBC to approve funding.
Understand that all applicants who give personal information to MNBC shall be required to consent to the release of that information to MNBC in order to comply with the BC Personal Information Protection Act (PIPA) and Freedom of Information and Protection of Privacy Act (FIPPA).
Declaration of truth and consent
I hereby agree to all of the above statements.
By signing you agree to the terms above.
Sign above
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Métis Elders and Seniors Assistance Program (MESAP) (WAITLIST)