1. Applicant Information (Information about the person completing this form)

By checking this box, I confirm that I am more than 18 years of age

2. How did you hear about Ceridian Cares?

Make A Selection

3. Recipient Information (information about the person who receives grant/benefits from the grant)


*Recipient is an employee or immediate family member of Ceridian

*immediate family member = spouse, domestic partner, parents, grandparents, stepparents, siblings, children and stepchildren of the Ceridian employee

Employee of Ceridian
Is recipient a Canadian resident ?
Notice of Assessment in the last taxation year [line 150]

4. Request Type

5. Confirmation and Consent

By checking this box, I confirm that everything I have submitted is correct and true, and I agree that if any information provided is found to be false, Ceridian Cares will pursue all rights and remedies available at law or in equity, and I shall pay and reimburse all grants provided and any legal fees Ceridian Cares incurs in pursuing such rights and remedies.

By checking this box, I agree that if I or the recipient receive or become eligible for funding of this need through another source, I have an obligation to notify Ceridian Cares and withdraw this application for grant and/or return any grant already awarded.

By checking this box, I confirm that I have obtained the consent of the recipient to provide Ceridian Cares the personal information within this submission (including but not limited to financials and medical supporting documentation)

By checking this box, I herdy authorize Ceridian Cares to collect, retain, and use the information provided in my capacity as applicant or potential grant recipient for the purposes outline herein and as further elaborated upon the Ceridian Cares Privacy Policy and Privacy Notice.

6. Release and Waiver

I hereby release and indemnify and save harmless Ceridian Cares and its subsidiaries, servants, agents, directors, officers, successors, assigns, employees and volunteers from and against any and all expenses related to all claims, demands, liabilities, losses, costs, damages, actions, suits or other proceedings of any nature or kind whomsoever sustained, brought or prosecuted in any manner whatsoever, at law or in equity, relating to this Application for Grant or any resulting funding, including without limitation based upon, occasioned by or attributable to the negligent act or omissions or the willful or reckless misconduct of the vendor/contractor in the fulfillment of utilizing the funds provided by Ceridian Cares.

Ceridian Cares acts solely as a third party funder and as such has no role in prescribing, recommending equipment, selecting a vendor/contractor and in the relationship between the recipient and vendor.

Payment from Ceridian Cares is not an acknowledgement that the work or equipment was acceptable. The recipient assumes full responsibility for all risks inherent in accepting funding from Ceridian Cares.

By checking this box, I agree to the Release and Waiver as described above.