Fillable Request for Service Day / Month / Year

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Request for Service Day / Month / Year

On average this form takes 16 minutes to complete

The Request for Service Day / Month / Year form is 3 pages long and contains:

  • 3 signatures
  • 41 check-boxes
  • 31 other fields

Country of origin: CANADA
File type: PDF

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Request for Service
DATE:
Day / Month / Year
Social Insurance Number:
Last Name:
First Name and Initials:
Married of Equivalent
Single
Prefer Not to Report
Email Address (must be personal email address):
Female
Male
Other
Prefer Not to Report
Mailing Address:
Preferred Method of Contact:
Regular Mail
Cell Phone
City:
Province:
Postal Code:
Number of Dependents:____
Prefer Not to Report
Preferred Language:
English French
Date of Birth:
Day / Month / Year
Home Phone:
Cell Phone:
Select areas you need assistance with:
Please complete:
Job Search/Resume Writing
ABE/High School Completion
Short-term Training (12 weeks or less)
Expected Start Date: ________________
Post-Secondary/Skills Training
Expected Start Date: ________________
Self-Employment
Career Counselling and Decision Making
OTHER _______________________
1. Are you currently in receipt of EI Benefits?
If YES, when does your existing claim expire?
_____________________.
If NO, when did your last claim expire?
_____________________.
2. Are you currently receiving Income Support from the
Provincial Government?
Yes No
Employment Status
Employed Approx. hrs per week: _____________
Unemployed (looking for work)
Self-Employed
Not in Labour Force (unemployed and not looking for work)
Education
Less than High School
High School or GED
College Diploma or Certificate
Some Post-Secondary
University Diploma or Certificate
University Degree
Other
Referral Source
Business Employers Community Organizations Immigration, Population Growth and Skills
Other Government Departments
Schools
Self-Referral
Are you requesting service because the company or business you work for has closed or is expected to close?
Yes No If yes, what is the name of the company or business: ___________________
PLEASE NOTE:
Your signed consent is required to process your request for
service.
Please complete the reverse of this page.
Government of Newfoundland and Labrador
Department of Immigration, Population Growth and Skills
Consent - Collection, Use and Disclosure of Personal Information
Collection: Personal information provided with your intake form / application for funding is collected under authority of
the Access to Information and Protection of Privacy Act, 2015 (ATIPPA, 2015), Employment Insurance Act of Canada,
Income and Employment Support Act and Regulations, and will only be used for the administration of the service or benefit
for which you are applying or for a consistent purpose under section 69 of ATIPPA, 2015.
Use: The personal information collected will only be used and/or disclosed in accordance with ATIPPA, 2015. Such uses
may include: determining services appropriate to the needs of the client, determining eligibility for programs and funding,
ensuring compliance with funding agreement terms, case management, tracking progress during an agreement including
post funding assessment of outcomes as per the information sharing agreement referenced between the Government of
Canada and the Government of Newfoundland and Labrador funded by the Department of Immigration, Population
Growth and Skills and to provide statistical information to agencies providing funding support to the services offered.
Disclosure: The personal information provided may be exchanged and released to any person, agency or government
departments, such as Immigration, Population Growth and Skills; Children, Seniors and Social Development; and Health
and Community Services, service provider organizations or training institution that is administering the program, service
or benefit. This information may include: contact information, employment plan, eligibility for employment insurance
benefits, marks, attendance and proof of financial payments to the training institution. The personal information provided
may also be shared with the Government of Canada and the Canada Revenue Agency in keeping with the data-sharing
provisions outlined in agreements between the Government of Newfoundland and Labrador and the Government of
Canada.
Access to Information and Protection of Privacy Act, 2015: Under ATIPPA, 2015 personal information is protected in
accordance with section 64.(1); you have the right to access your personal information protected in accordance with
section 8.(1); and you have the right to request the correction of your personal information protected in accordance with
section 10.(1) if there has been an error or omission. You have the right to withdraw this consent at any time by contacting
the Department of Immigration, Population Growth and Skills.
If you have any questions regarding how your personal information is collected or used, you may contact the ATIPP
Coordinator of the Department of Immigration, Population Growth and Skills. A listing of all departmental coordinators
and their contact information can be found at: www.atipp.gov.nl.ca/info/coordinators.html
.
Client Consent: I, (print name) _________________________________ acknowledge that I have read and understand the
above information regarding the collection, use and disclosure of my personal information.
Spouse Consent: I, (print name) _________________________________ acknowledge that I have read and understand
the above information regarding the collection, use and disclosure of my personal information.
Parent, Guardian or Trustee Consent: I, (print name) _________________________________ (Parent, Guardian or
Trustee) acknowledge that I have read and understand the above information regarding the collection, use and disclosure
of information regarding my dependent. Print name of dependent: ___________________________________.
_________________________________ ____________________________
Signature of Client Date (dd/mm/yyyy)
_________________________________ ____________________________
Signature of Spouse Date (dd/mm/yyyy)
_________________________________ ____________________________
Signature of Parent, Guardian or Trustee Date (dd/mm/yyyy)
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CHECKLIST
Ensure all sections of the Request for Service form have been completed.
Ensure your name has been printed in the Consent form and you have signed and dated
the form.
Ensure the consent form has spousal names, signatures and dates, if applicable.
Completed forms can be returned to the Department by email at:
employmentprograms@gov.nl.ca
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Request for Service Day Month Year

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Completed 3 June 2021

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