"Mobility and Adaptive Equipment Loan Program Landlord Permission to Install" - New Brunswick, Canada

ADVERTISEMENT
ADVERTISEMENT

Download "Mobility and Adaptive Equipment Loan Program Landlord Permission to Install" - New Brunswick, Canada

Download PDF

Fill PDF online

Rate (4.8 / 5) 27 votes
Page background image
MOBILITY AND ADPATIVE EQUIPMENT LOAN PROGRAM
LANDLORD PERMISSION TO INSTALL
Reference:
Date: _____
_____ _____
dd
mm
yy
Client name:
__________________________________
__________________________________
Address:
City: ________________
Province:
__________________________________
Postal Code: ___________
Dear Sir or Madam:
Your tenant (named above) has been prescribed medical equipment which will be funded by the
Department of Social Development Mobility and Adaptive Equipment Loan program.
The following equipment will be required to be professionally installed by a licensed service
technician and all costs associated with the installation will be covered by Social Development.
Equipment type
Location of installation
1.
2.
3.
The department requires your permission before the equipment is installed at the address above.
Please check the box below to indicate your response and provide your signature and the date.
Once this is completed please return it to the prescribing therapist.
 I do give permission to have this equipment installed by a licensed service technician who is
under contract with Social Development.
 I do give permission to have the equipment installed by a licensed service technician but wish to
be present when the installation is completed.
 I do not give permission to have the equipment installed
Landlord Information:
First
Last Name: _____________________________
_________________________
Name:
Contact #:
______________________ Signature:
___________________________________
Prescribing therapist contact information:
Name:
______________________________
E-mail:
__________________________
Ph. #:
______________________________
Fax #:
___________________________
Department of Social Development / Ministère du Développement social
MOBILITY AND ADPATIVE EQUIPMENT LOAN PROGRAM
LANDLORD PERMISSION TO INSTALL
Reference:
Date: _____
_____ _____
dd
mm
yy
Client name:
__________________________________
__________________________________
Address:
City: ________________
Province:
__________________________________
Postal Code: ___________
Dear Sir or Madam:
Your tenant (named above) has been prescribed medical equipment which will be funded by the
Department of Social Development Mobility and Adaptive Equipment Loan program.
The following equipment will be required to be professionally installed by a licensed service
technician and all costs associated with the installation will be covered by Social Development.
Equipment type
Location of installation
1.
2.
3.
The department requires your permission before the equipment is installed at the address above.
Please check the box below to indicate your response and provide your signature and the date.
Once this is completed please return it to the prescribing therapist.
 I do give permission to have this equipment installed by a licensed service technician who is
under contract with Social Development.
 I do give permission to have the equipment installed by a licensed service technician but wish to
be present when the installation is completed.
 I do not give permission to have the equipment installed
Landlord Information:
First
Last Name: _____________________________
_________________________
Name:
Contact #:
______________________ Signature:
___________________________________
Prescribing therapist contact information:
Name:
______________________________
E-mail:
__________________________
Ph. #:
______________________________
Fax #:
___________________________
Department of Social Development / Ministère du Développement social
2
Page of 2