Service Registration Intake Form

Service Registration Intake Form

Newfoundland and Labrador Settlement and Integration Program (NLSIP)
Personal Information:

UCI:
Name

First NameMiddle NameLast Name
Gender:

MaleFemaleOther/XPrefer not to report
Birthdate:

MonthDayYear
Age Category:
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Email
example@example.com
Service Language

EnglishFrench
Francophone:
Other Languages Spoken:
Translation/Interpretation Received:
Language of Translation/Interpretation:

Temporary Foreign Worker:
Visible Minority:
Civic Address:

Street Address

Street Address Line 2

CityProvince

Postal Code
Country:

Additional Information:
Service Registration Intake Form

Newfoundland and Labrador Settlement and Integration Program (NLSIP)
Intake - Country of Birth:
Intake - How any dependents do you have under age 12? (please also list if they are male or female):
Intake - How many dependents do you have over 12 years and under 18 years? (please also list if they are male or female)
Intake - How many dependents do you have 18 years and older? (please also list if they are male or female)
How did you find out about our services/supports?

Service Registration Intake Form

Newfoundland and Labrador Settlement and Integration Program (NLSIP)
By entering into an agreement with the Department, proponents agree to public disclosure of their proposal content. Any information in the proposal that the proponent considers proprietary should be marked as "confidential" and will be subject to appropriate consideration as defined within Access to Information and Protection of Privacy Act (ATIPPA). Submitted proposals, and content within, become property of the Government of Newfoundland and Labrador.

Evaluation reviews made public through ATIPPA will not include any materials deemed proprietary in nature. If selected agencies have access to immigrants' personal information that is protected under ATIPPA, agencies should understand that they may not disclose or reveal any such personal information. Failure to comply with these regulations may result in criminal prosecution or civil liability of the agency and the individual(s) involve.

We do not disclose your personal information to other organizations or individuals except as required to fulfill the purpose(s) of the program or service and only to the extent required or authorized by law.

Some functions within these programs or services are provided by service providers external to the department(s). All external service providers that provide you with services on our behalf must comply with our privacy requirements and must meet the applicable security, privacy, and terms of use provisions.

Under the privacy provisions of the ATIPP Act individuals have the right to correction of, and access to, their personal information. To obtain access or request correction of your personal information please contact the ATIPP Office by phone at (709) 729-7072 or (877) 895-8891, or by email at atippoffice@gov.nl.ca for assistance.
I acknowledge that I have read and understand the above information regarding the collection use, and disclosure of my personal information.
Client Name (Print)
First + Last Name of Witness:
Should be Empty:

Service Registration Intake Form

Personal Information:

Additional Information:

Service Registration Intake Form

Service Registration Intake Form

Service Registration Intake Form