Individual Registration Form

If you are looking to become a registered client, please complete this Individual Registration Form to the best of your ability.   This form is electronically forwarded to us and we will contact you shortly to discuss your ability to visit our centre to access our services.  The more information we have, the more we will be able to determine the level of service you need in order to best help you.

Note that some fields (marked with a *) are required.

When you are finished, be sure to click SEND at the very bottom of the page.

Part 1: Personal Information

Please note: This form is for people who are eligible to work in Canada.

If you live in Canada but are ineligible to work, please do not complete this form.

If you live in a foreign country and are interested in moving to Canada, please contact the Canadian embassy in your country for immigration information.

First Name* (required)
Last Name* (required)
Middle Initial
Birthdate* (required):
Service language:
Home phone:
Other language:
Mobile phone:
Marital status:

Your Email

Part 2: Mailing Address

Care of:

Street Address* (required)

Town* (required):


Postal Code*:


Part 3: Civic Address (if different from mailing address):

Street address:




Postal code:

Part 4: Registration Details

Employment Status:
Employment Details:
Variable hoursSelf-employedSeasonalPart timeFull timeN/A
Work hours/week:

Hourly wage:

Expected layoff date (if you have one):

Part 5: Education

Are you a student? YesNo
If yes, what kind? Full time - Secondary PrepFull time - SecondaryFull time - Post SecondaryPart time - Secondary PrepPart time - SecondaryPart time - Post Secondary
Have you applied for or received EI in the last 36 months? YesNo
If yes to the above, what type of claim was it? RegularMaternityPaternalMedicalCompassionate CareUnknown
Have you had a medical, parental, or sick leave claim that ended in the last 36 to 60 months? YesNoUnknown
If yes to the above, what kind of claim was it? Maternity/ParentalSick
Are you legally entitled to work in Canada? YesNoUnknown
Are you currently involved with another agency? YesNo
What language would you like to correspond in? FrançaisEnglish
What is your preferred correspondence method? EmailTelephoneRegular post

Collection, Use, and Disclosure of Personal Information

Please read the information below before clicking SEND. Hitting SEND confirms that you have read the information on collection, use, and disclosure of personal information and that you agree to these terms.

COLLECTION: Personal information provided with your intake form/application for funding is collected under the authority of the Nova Scotia Freedom of Information and Protection of Privacy Act and the Employment Insurance Act of Canada and will be used only for the administration of the service for which you are applying.

USE: The personal information collected will only be used and disclosed in keeping with the access and privacy provisions of the Nova Scotia Freedom of Information and Protection of Privacy Act and then Nova Scotia Personal Information International Disclosure Protection Act. 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 funded by Employment Nova Scotia and to provide statistical information to agencies providing funding support to the services offered.

DISCLOSURE: The personal information provided may be shared with a Service Provider Organization, Employment Nova Scotia, and/or a Training Institution that is administering a program or service. This information may include: contact information, return to work action plan, eligibility for employment benefits, marks, attendance, and proof of financial payments to the training institution. The personal information provided may also be shared with the Government of Cnada and the Canada Revenue Agency in keeping with the data-sharing provisions of the Labour Market Development Agreement or Labour Market Agreement. In keeping with the provisions of the NS Personal Information International Disclosure Protection Act, personal information collected will not be disclosed or stored outside of Canada unless legally authorized.

ACCESS: Under the privacy provisions of the Nova Scotia Freedom of Information and Protection of Privacy Act individuals have the right to protection of, and access to, their personal information. TO obtain access to, or correction of personal information used and collected, individuals must submit a written request to the Nova Scotia Department of Labour and Advanced Education. Requests should be directed to the Employment Nova Scotia Agreement Manager.