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I acknowledge that this request is valid for one year only and must be renewed on a yearly basis. Signature Date 235 Mont e Lesage Rosem re QC J7A 4Y6 Telephone 450-621-5600 Fax 450-621-7951 Step 2 TO BE COMPLETED BY THE MEDICAL SPECIALIST Visual impairment partial sight Permanent physical impairment excluding chronic disabilities blindness Please specify Permanent chronic physical impairment Epilepsy not controlled by medication Non-permanent chronic physical disability From to Asthma...
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