Application Application Checklist Please use this checklist to ensure that your application contains all required information at the time you submit your application. Applications missing required information will NOT be processed. Required Information All sections of the Application Form (pages 2-4) have been completed. Application is signed at the bottom of page 4. On the top of page 5, your legal name must be entered in the space provided. This is the first page of the Agreement. I have carefully read pages 5-7 of the Agreement If you are approved these will be the terms and conditions upon which Employment Nova Scotia will approve and monitor your agreement. If you have any questions, please contact us before signing and submitting the application. The Agreement is signed and dated at the bottom of page 7 Collection, Use & Disclosure of Personal Information Form is signed and dated at the bottom of page 8. NSCC Client Consent to Release Form is signed and dated at the bottom of page 9 (must be signed by NSCC students only). A letter Issued by the training institution providing confirmation of acceptance or proof of enrollment to the training program is included (application will not be processed without this letter). Important Information Applications must be submitted to your local office. Please visit our website at http://www.novascotia.ca/employmentnovascotia/contact/ for a list of local offices or contact us at 1-877-223-0888. 1
Application Identification Information Program: Application Last name SIN First name Middle initial Date of Birth Phone number Email Address Male Female Current Address Street address City Province/State Country Postal/Zip code Temporary Address (address while attending school if different than your current address) Street address City Province/State Country Postal/Zip code Residency Status Canadian Citizen Permanent Resident Other 2
Application Employment Status Are you currently employed? Yes No If Yes, please provide details: Will you be returning to your employer? Yes No If Yes, what is your return to work date? EI Benefits Payable Are you currently on an EI claim? Yes No If no, will you be applying? Yes No If yes, please provide date applying: Have you been out of Secondary School (High School) for a minimum of 12 consecutive months? Yes No Labour Market Information What is your employment goal? Please describe the prospects for employment in this field. 3
Application Course Information Please provide details on the course you are requesting funding to attend. Course Name Start Date End Date Classroom/Training Hours per week Training Institution Name & Campus Classroom/Training Participation Full-time Part-time Training Institution Location You MUST attach a letter issued by the training institution providing confirmation of acceptance or proof of enrollment to the training program. Please describe the how this training program will help you find employment in your chosen field. Financial Plan Do you have a financial plan in place to cover costs once your EI claim has ended? Yes No Signature I hereby certify that the information provided above is true and accurate. Name (please print) Signature Date 4
Agreement BETWEEN: AND: Agreement Labour and Advanced Education (hereinafter referred to as the PROVINCE) Name (please print) (hereinafter referred to as YOU) General Terms and Conditions 1. Privacy and Access to Information Information on this form is collected under the authority of the Employment Insurance Act and the Nova Scotia Freedom of Information and Protection of Privacy Act and is to be used for administration of the employment benefit to which You have applied. To obtain access to, or to request correction of, your personal information collected and used by NS Labour & Advanced Education please contact the PROVINCE s Information Access and Privacy Manager by email LAEaccess@gov.ns.ca or phone (902) 424-8472. Personal information provided may be shared with Canada Revenue Agency in keeping with the data-sharing provisions of the Labour Market Development Agreement. 2. Performance 2.1 Pursue the course or Activities diligently and complete them successfully within the Agreement Period. 2.2 Attend and Participate in the course or Activities on a full time basis, unless explicitly stated in your Agreement. 2.3 YOU acknowledge and agree to promptly communicate to the PROVINCE, in writing: a) any breaks in the course or in the performance of Activities as described in Schedule A ; b) if YOU reduce your participation in the course or Activities; c) if YOU complete the course or Activities early (i.e. prior to the end of the Agreement Period); d) if YOU are failing to successfully complete the course or Activities within the Agreement Period; e) if the course or Activity start/end dates change; f) if YOU intend to withdraw from participation in the course or Activities; g) absence from course or Activities greater than 5 days. 3. Reevaluation Upon receipt of communication as described in section 2.3, the PROVINCE may reevaluate your eligibility to continue participation under the Program and/or your ability to successfully complete the course or Activities. 5
Agreement 4. Termination for Default The following constitute events of default: a) if the course or Activity is cancelled, on the date the cancellation is effective,; b) if YOU withdraw from the course or Activity, on the last date you attend; c) if YOU are expelled from the course or Activity, on the date expelled, d) if YOU complete the course or Activity early, on the date of course or Activity completion; e) If YOU, in support of the application or in connection with this Agreement, have made materially false or misleading declarations, representations or statements, or provided materially false or misleading information to the Province; and f) If YOU are in breach of the performance of, or compliance with, any term, condition or obligation on your part to be observed or performed pursuant to this Agreement. If an event of default as specified in section 4 has occurred the Province may immediately terminate the Agreement by written notice. Upon providing such notice of termination, the Province shall have no obligation to make any further contribution to YOU. 5. Following Expiry/Termination YOU agree to inform the Province promptly in writing of any changes to your mailing address for a period of 1 year following expiry or termination of this agreement. 6. Survival of Provisions Any terms and conditions in this Agreement which require their performance by the Parties after the expiration or termination of this Agreement shall be and remain in force notwithstanding such expiration or termination of this Agreement. 7. Notices 7.1 Any notices to be given, and all reports, information, correspondence and other documents to be provided, by either Party under this Agreement shall be given or provided if personally delivered or sent by mail, courier service, fax or by electronic submission at the address, or fax number, as the case may be, of the receiving party. 7.2 Notices, reports, information, correspondence and other documents that are delivered personally or by courier service shall be deemed to have been given or provided on the date of personal delivery or delivery by the courier service, or if sent by mail, eight (8) calendar days after the date of mailing, or in the case of notices and documents sent by fax or by electronic means, one (1) working day after they are sent. 8. Amendment No amendment of any of the terms or provisions of this Agreement is valid unless it is in writing and signed by both Parties. 9. Severability Should any term or provision of this Agreement be found to be invalid or unenforceable, the remainder of this Agreement shall continue and be enforceable and any invalid term or provision shall be severable. 10. Province s Representative All references in this Agreement to the PROVINCE include any person authorized to act on behalf of the PROVINCE in respect of this Agreement. 11. Counterparts This Agreement may be signed by the Province and YOU in separate counterparts, each of which when signed and delivered shall be an original. 6
Agreement 12. Singular/Plural Where the context so requires, words in the singular include the plural and vice versa. 13. Governing Law This Agreement shall be governed by and interpreted in accordance with the laws of Nova Scotia and the applicable laws of Canada and the courts of Nova Scotia shall have exclusive jurisdiction over any dispute or lawsuit between the Parties. 14. Note to Active EI Claimants Regarding Referral Under Section 25 of the Employment Insurance Act: Under Section 25 of the Employment Insurance Act, a claimant is unemployed, capable of and available for work and therefore eligible to receive insurance benefits ("EI benefits") when the claimant is participating in an employment activity, attending a course, program of instruction, or training under an employment benefit, to which the PROVINCE, or an authority designated by the PROVINCE, has referred the claimant. Failure to meet the conditions of your referral under Section 25 may result in the loss of your entitlement to receive your EI benefits. 15. If you end the agreement early Reasons for not completing the full term of the Agreement must be provided. These reasons will be communicated to EI. If YOU leave the program without cause YOU may lose your remaining eligibility to EI benefits. Financial Support 1. I understand that the only financial support I will receive is my EI Benefits and that I must submit bi-weekly reports to Service Canada as required. If my EI claim ends, there will be no other funds provided unless I have sufficient hours for a new EI claim and have served the waiting period for the new claim. 2. I understand that I must notify in the event that I have sufficient hours for a new EI claim. EI funding under the program will not be automatically continued when a new EI claim is established. 3. I understand that I will be responsible for all training related costs. Signature Please note: If you are subject to a garnishment under the Family Orders and Agreement Enforcement Assistance Act any benefits which you receive from this program are eligible for garnishment. You may wish to contact your Maintenance Enforcement Officer to discuss reducing your garnishment amount. I hereby certify that the information provided above is true and accurate. Your signature on this agreement is also considered authorization for the training institution to: (a) Provide the Province with your attendance records and progress reports (b) Notify the Province in the event you are expelled/dismissed, if you are failing, or if you withdraw from the approved training program prior to the date of completion Name (please print) Signature Date 7
COLLECTION, USE, & DISCLOSURE OF PERSONAL INFORMATION COLLECTION: The personal information you have provided is collected under the authority of the Nova Scotia Freedom of Information & 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 the 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 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, the Department of Community Services, 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 Canada and the Canada Revenue Agency in keeping with the data-sharing provisions of the Labour Market Development Agreement or Labour Market Agreement. 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 request correction of, your personal information collected and used by NS Labour and Advanced Education please contact the department s Information Access and Privacy Manager by email LAEaccess@gov.ns.ca or phone (902) 424-8472. I acknowledge that I have read and understand the above information regarding the collection, use, and disclosure of my personal information: Client name [print] Social Insurance Number Client signature Date Version: 2.0 June 2014 9
CLIENT CONSENT to RELEASE FORM In order to facilitate the exchange of my personal information among _, Case Management Agency (Print) Address (Print) and my educational institution, Nova Scotia Community College, I, Name of Client/Student (Print) Student ID Number Month and Year Program Starts hereby consent to the disclosure and/or use of the following information: Contact information (name/address/phone/email) Application status Financial status (in good standing/in arrears) Student status (active/inactive/fulltime/parttime) solely for the purpose of determining my ongoing eligibility for support from for studies at NSCC. The above mentioned information may be disclosed to the identified external case management agency and/or. Client/ Student Signature Date Revised April, 2013 ENS Steering Committee 10