Select dne: | am a medical doctor | am a nurse practitioner Contact Information [ Tobe completed by at modal doctrs and nurse practi sae) |Name Leen registration umber \ a : ts is | | Apartment number Street number and name Cayertoen Te | | eemearicnayesia Pala DP cote Peter aay eA h | Cie Medical doctors and nurse practitioners outside Canada must also provide the following information: 2 \ [ unwersty where cries obtained ‘Yoor corti clained Country of prncsco | ss | oan e cs ton | y {oie e ted by Employment and Social Development Canada under the authority of the ver benefits of one or more caregivers. For more information about Family Lense /egistation number The information provided on this form is collect EIAct to determine the eligibility for Family Care Caregiver benefits, go to canada.ca. 1ed is administered in accordance with the Department of Employment and Social Development Aatand the Privacy Act Individuals have the right to the protection of and access to their personal information. Information will pe ielained for 6 years after the last administrative action, as described in Personal Information Bank, Insurance Claim File - I [eeal Office, ESDC PPU 150, Instructions for obtaining this information are outlined in the government publication entited info |] Seurce-"wrich is available a the folowing address: htto//canada.calinfosoutce-ESDC. Info Source may also be accessed online at any Service Canada Centre. ‘The personal information collect e of SSC INS52426 (2019-05-004) E Ee