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Es No I hereby certify that the information given above is correct. Date Health Care Professional Signature (YY/MM/DD) For Office Use Only Received by: Date: (YY/MM/DD) Registration # assigned: The personal information on this form is collected under the authority of Section 11 of the Municipal Act, as amended and the Town s ActiVan Program. The information is used for the purpose of processing this application and administering the program. Questions regarding the collection of this in.

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  2. Fill out the requested boxes that are yellow-colored.
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