Actuel Page 1 Page 2 Aperçu 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? If yes, enter your civic address in the fields below. - Sélectionner -YesNo 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 Gender Date of Birth Numéro de carte-santé (NCS) Tapez les huit chiffres de votre carte-santé de l’Î.-P.-É. Social Insurance Number (SIN) Is the mailing address different than above? - Sélectionner -YesNo Mailing Address Address 1 Address 2 City, Town, or Community Province Postal Code For example C1B 0X1 or 12345