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This form is to be completed by a physician (medical doctor).

I hereby certify that (Full name of patient)

___________________________________________________,

has a disability.

Full name (please print) ____________________________________

Identification number ____________________________________

Number / Street / PO Box # ____________________________________

City ____________________________________

Province / Territory ____________________________________

Postal Code ____________________________________

Telephone number with area code ____________________________________

Signature of physician ____________________________________

Date (DD/MM/YYYY) ____________________________________