Request for Service

"*" indicates required fields

Are you an individual impacted by the wildfires?*

Yes

Social Insurance Number:*

Date of Birth: DD-MM-YYYY*

Day

Month

Year

Last Name:*

First Name and Initials:*

Phone:*

Preferred Language:

English

French

Gender:

Male

Female

Other

Prefer not to answer

Marital Status:

Single

Married or Equivalent

Prefer Not to Report

Preferred Methods of Contact:*

Phone

Regular Mail

Number of Dependents:

Email Address (must be personal email address):

Mailing Address:

Street Address Address Line 2 City Province Postal Code

Please complete:

Select areas you need assistance with:

Job Search/Resume Writing

ABE/High School Completion

Short-term Training (12 weeks or less)

Post-Secondary/Skills Training

Self-Employment

Career Counselling and Decision Making

OTHER:

Other:*

Expected Start Date: DD-MM-YYYY

Day

Month

Year

1. Are you currently in receipt of EI Benefits?*

Yes

If YES, when does your existing claim expire? DD-MM-YYYY

Day

Month

Year

If NO, when did your last claim expire? DD-MM-YYYY

Day

Month

Year

2. Are you currently receiving Income Support from the Provincial Government?

Yes

Employment Status:

Unemployed (looking for work)

Self-Employed

Employed

Not in Labour Force (unemployed and not looking for work)

Approximate hours per week:

Education: (Check all that apply)

Less than High School

High School or GED

College Diploma or Certificate

Some Post-Secondary

University Diploma or Certificate

University Degree

Other:

Referral Source: (Check all that apply)

Business Employers

Community Organizations

Department of Families and Affordability

Other government departments (please indicate)

Schools

Self-Referral

Other:

Are you requesting service because the company or business you work for has closed or is expected to close?

If YES, what is the name of the company or business?

Consent - Collection, Use and Disclosure of Personal Information*

I acknowledge that I have read and understand the below information regarding the Collection, Use, and Disclosure of my/my dependent's personal information. NOTE: If the client is under the age of 18, the below consent form must be acknowledged and signed by a Parent, Guardian or Trustee.

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, 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 Jobs, Growth and Rural Development 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 Jobs, Growth and Rural Development; Social Supports and Well-Being; 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 Jobs, Growth and Rural Development.

If you have any questions regarding how your personal information is collected or used, you may contact the ATIPP Coordinator of the Department of Jobs, Growth and Rural Development at ATIPP-JGRD@gov.nl.ca. A listing of all departmental coordinators and their contact information can be found here.

First Name (Client):*

Last Name (Client):*

Signature of Client:*

To sign your name, use your finger, mouse or other compatible input device inside the dotted box. To start signing, press or click, hold and move. To stop signing, lift or release. To clear the signature, press or click the arrows icon in the bottom right corner.

Today's Date: DD-MM-YYYY*

Day

Month

Year

First Name (Parent, Guardian or Trustee):

Last Name (Parent, Guardian or Trustee):

First Name (Dependent):

Last Name (Dependent):

Signature of Parent, Guardian or Trustee:

Today's Date: DD-MM-YYYY

Day

Month

Year

Creating web-based form to replace the pdf

"*" indicates required fields

Are you an individual impacted by the wildfires?*

Yes

Social Insurance Number:*

Date of Birth: DD-MM-YYYY*

Day

Month

Year

Last Name:*

First Name and Initials:*

Phone:*

Preferred Language:

English

French

Gender:

Male

Female

Other

Prefer not to answer

Marital Status:

Single

Married or Equivalent

Prefer Not to Report

Preferred Methods of Contact:*

Phone

Regular Mail

Number of Dependents:

Email Address (must be personal email address):

Mailing Address:

Street Address Address Line 2 City Province Postal Code

Please complete:

Select areas you need assistance with:

Job Search/Resume Writing

ABE/High School Completion

Short-term Training (12 weeks or less)

Post-Secondary/Skills Training

Self-Employment

Career Counselling and Decision Making

OTHER:

Other:*

Expected Start Date: DD-MM-YYYY

Day

Month

Year

1. Are you currently in receipt of EI Benefits?*

Yes

If YES, when does your existing claim expire? DD-MM-YYYY

Day

Month

Year

If NO, when did your last claim expire? DD-MM-YYYY

Day

Month

Year

2. Are you currently receiving Income Support from the Provincial Government?

Yes

Employment Status:

Unemployed (looking for work)

Self-Employed

Employed

Not in Labour Force (unemployed and not looking for work)

Approximate hours per week:

Education: (Check all that apply)

Less than High School

High School or GED

College Diploma or Certificate

Some Post-Secondary

University Diploma or Certificate

University Degree

Other:

Referral Source: (Check all that apply)

Business Employers

Community Organizations

Department of Families and Affordability

Other government departments (please indicate)

Schools

Self-Referral

Other:

Are you requesting service because the company or business you work for has closed or is expected to close?

If YES, what is the name of the company or business?

Consent – Collection, Use and Disclosure of Personal Information*

I acknowledge that I have read and understand the below information regarding the Collection, Use, and Disclosure of my/my dependent’s personal information. NOTE: If the client is under the age of 18, the below consent form must be acknowledged and signed by a Parent, Guardian or Trustee.

First Name (Client):*

Last Name (Client):*

Signature of Client:*

Today's Date: DD-MM-YYYY*

Day

Month

Year

First Name (Parent, Guardian or Trustee):

Last Name (Parent, Guardian or Trustee):

First Name (Dependent):

Last Name (Dependent):

Signature of Parent, Guardian or Trustee:

Today's Date: DD-MM-YYYY

Day

Month

Year

Jobs, Growth and Rural DevelopmentRequest for Service

Please complete:

Request for Service

Please complete:

Jobs, Growth and Rural Development
Request for Service