ASETS APPLICATION. Are you receiving Income Support. Name Age Date of Birth Relationship Living with me. Emergency

Transcription

1 Inuvialuit Reginal Crpratin Human Resurces, Educatin & Training Department ASETS Prgram Tll Free: Fax: CRF EI PERSONAL IDENTIFICATION SIN Surname ASETS APPLICATION Title Given Name Gender Male Female Date f Birth LEGAL IDENTIFICATION Citizenship CANADIAN Marital Status Single Married Cmmn-law Widwed Preferred Language ENGLISH Spuse Name D yu have a Disability Yes N Number f Dependents D yu identify as a Visible Minrity Yes N Are yu receiving Incme Supprt Yes N DEPENDENT INFORMATION Dependent(s) Must be living with yu and under 18 years f age Name Age Date f Birth Relatinship Living with me ABORIGINAL IDENTIFICATION Abriginal Grup INUVIALUIT Beneficiary N. Cmmunity Crpratin Aklavik Inuvik Paulatuk Sachs Harbur Tuktyaktuk Ulukhaktk ADDRESS Mailing Address CONTACT INFORMATION Hme Phne Address Wh t Cntact in Case f Emergency Cell Phne Emergency Cntact Number EDUCATION INFORMATION (indicate if graduated) Level Institutin Prgram Year- Cmpleted Examples fr Level: High, Schl, License, Certificatin, Diplma, Degree, Undergraduate, Masters, Dctrate

2 TRADE INFORMATION Trade Level Years f Experience CERTIFICATES Certificatin Level Expiry Date DRIVERS LICENCE Class Number Prvince/Territry Expiry Date EMPLOYMENT HISTORY (Please attach an up t date resume) Emplyer Title Start Date End Date Reasn fr Leaving EMPLOYMENT GOALS Emplyment Gals Plan t Succeed BARRIERS (Identify each barrier yu face) Emplyment Barriers Plan t Overcme Lack f labr frce attachment Lack f wrk experience Lack f transprtatin Remteness Language Educatin Ecnmic Dependent care Lack f marketable skills Physical, emtinal r mental health Other ASETS Applicatin revised January 2019 Page 2 f 5

3 PROGRAM APPLIED TO (Or ther funding request) Prgram Institutin Lcatin Accepted Cnfirmatin Pending Start Date End Date: Year f a Year Prgram Level Full Time Part Time Distance Educatin Examples fr Level: High Schl Diplma, License, Certificatin, Diplma, Degree, Undergraduate, Masters, Dctrate * Please attach crrespndence (required) NWT STUDENT FINANCIAL ASSISTANCE (Deadline dates are July 15 th and January 15 th ) Applied fr SFA Yes N Status f applicatin Apprved Denied If N, please explain why * Please attach crrespndence (required) EMPLOYMENT INSURANCE BENEFITS Are yu receiving EI Yes N If answer is Yes start date Wrked full-time in last 6 mnths Yes N Received EI last 3-5 Years Yes N BUDGET PLAN (ask fr assistance if required) Descriptin Ntes SFA Funding ASETS Funding Tuitin and Fees Transprtatin Required Bks and Supplies Living Allwance Child Care Csts Other (case by case) TOTAL BANKING INFORMATION Clients applying fr a living allwance must have a CIBC banking accunt. Payments are made by direct depsit nly and a Direct Depsit frm (frm the bank) must be prvided t cnfirm banking details. We have supplied ne fr yur cnvenience. RECOMMENDATIONS OFFICE USE: APPLICATION RECEIVED DATE ASETS CASE MANAGER APPROVAL DATE CODING ASETS Applicatin revised January 2019 Page 3 f 5

4 CONSENT CLAUSE, DECLARATION AND RELEASE OF INFORMATION (Please read carefully) 1. I cnsent t and authrize the release f any persnal infrmatin by my emplyer, banks r ther financial institutins, mercantile rganizatins, abriginal rganizatins, educatinal institutins and by federal, prvincial, territrial and municipal gvernment departments and agencies, including the Canada Custms and Revenue Agency t the Inuvialuit Reginal Crpratin. My persnal infrmatin will be used t determine my initial and cntinued eligibility fr funding and fr the effective and efficient general administratin and enfrcement f the IRC ASETS Prgram. 2. In additin, I cnsent t and authrize the Inuvialuit Reginal Crpratin t the release f any persnal infrmatin t any abriginal rganizatins and/r federal, prvincial, territrial and municipal gvernment departments and agencies t assist me in the purpse f the effective planning, develpment, delivery and mnitring f the IRC ASETS Prgram. 3. I understand that persnal infrmatin means and includes: my name, hme r business addresses r hme and business telephne numbers, my natinal r ethnic rigin; my age, sex, marital status r family status, and date f birth, my financial status and histry; any identifying numbers, symbl r ther self-identifying assigned t me such as my scial insurance number, health care card number, r persnal identificatin number; infrmatin abut my educatinal r emplyment status and histry. 4. I understand that the persnal infrmatin that may be released t banks r ther financial institutins, mercantile rganizatins, abriginal rganizatins, gvernment rganizatins and educatinal institutins are: my name, hme r business addresses r hme and business telephne numbers; my natinal r ethnic rigin; my age, sex, marital status r family status, date f birth; and my financial status and histry. I agree t prvide such additinal cnsent t the release f my persnal infrmatin as may be required frm time t time by the Inuvialuit Reginal Crpratin. DECLARATION I declare that the infrmatin submitted in this frm and appendices are crrect t the best f my knwledge. I agree t: use any funding received frm the IRC ASETS funds twards the cst f my educatin and return any refunds f tuitin r ther fees and any IRC Emplyment and Training funding that I am nt entitled t; immediately ntify the IRC ASETS staff if I change my status as a full-time student in an apprved prgram, my study perid, my marital status, the status f my dependents r financial status, any changes t my address(s), phne numbers and bank accunts; prvide infrmatin r dcuments requested by the IRC ASETS staff t verify any statement made in this applicatin; and t fllw the terms and cnditins f any funding dcuments that I may receive. ASETS Applicatin revised January 2019 Page 4 f 5

5 I understand that: all training funds are cnsidered incme under the Incme Tax Act (Canada). IRC is bligated t reprt the amunt f the Cntributin n a T4A, prvide the T4A t me, and I am required t include the amunt f the Cntributin when cmputing my incme fr the fiscal year; I may have t repay my financial assistance nw r in the future t the Inuvialuit Reginal Crpratin if there are changes t my financial, marital, dependents r my status as a full-time student in an apprved prgram; I may be denied financial assistance nw and, in the future, if: I make false r misleading statement in this applicatin; I d nt cmply with a request frm the IRC ASETS Prgram t prvide infrmatin r dcuments s that infrmatin in this applicatin may be verified; my eligibility fr IRC ASETS funds may be affected by incme that I, r my spuse, receive frm ther surces; and I have an utstanding debt t the Inuvialuit Reginal Crpratin r its affiliates r t ther funding agencies. I cnsent t and authrize the release f any persnal infrmatin by Inuvialuit Reginal Crpratin. My persnal infrmatin may be used fr effective planning and delivery f career develpment and emplyment initiatives f the IRC Career Centre. SIGNATURES Applicant Signature IRC ASETS Signature Date Date ASETS Applicatin revised January 2019 Page 5 f 5