Application for Family Housing

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Personal information on this form is collected under the Provincial Health Number Act R.S.P.E.I. 1988, Cap. P-27.01 and section 31 of the Freedom of Information and Protection of Privacy Act R.S.P.E.I. 1988, Cap. F-15.01, as it relates directly to and is necessary for the provision of the Seniors Home Repair Program. If you have any questions about this collection of personal information, you may contact the Department of Family and Human Services at 1-902-368-5770.

Identification

Do you have a fixed address?

First Name

Middle Initial

Last Name

Address 1

Address 2

City, Town, or Community

Province

Postal Code

For example C1B 0X1 or 12345

Country

Telephone Number

For example 902-555-5555

Email Address

First Name

Middle Initial

Last Name

City, Town, or Community

Telephone Number

For example 902-555-5555

Email Address

Gender

Date of Birth

Personal Health Number (PHN)

Please enter the 8-digits from your PEI health card.

Is the mailing address different than above?

Mailing Address

Address 1

Address 2

City, Town, or Community

Province

Postal Code

For example C1B 0X1 or 12345