Funeral Service Registration

Funeral Cost Coverage Program

Principal Applicant must be Canadian Citizen or Permanent Resident living in Halton Region including Waterdown.
Principal Applicant:
Full Name*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

DayMonthYear
Date
Phone Number*
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Spouse's Info:
Spouse's Full Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Phone Number
E-mail
example@example.com
Dependent Children: (Unmarried Only)
*Married children will have to apply separately.

Dependent Parents: (Principal Applicant's Only)
*Spouse's Parents will have to apply separately.
Father's Name (if alive)

First NameLast Name
Date of Birth of Father

DayMonthYear
Date
Mother's Name (if alive)

First NameLast Name
Date of Birth of Mother

DayMonthYear
Date
Address (If different from the Principal Applicant's Address)

Street Address

Street Address Line 2

CityProvince

Postal Code
Banking Information

Please attach Void Cheque to show Bank Name, Account Number, Branch Code and Account Holder Name.
Upload VOID Cheque!*

(pdf, doc, docx, jpg, jpeg, png, gif)
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Funeral Cost Coverage Program