New client disclaimer form | Immigrant Centre Manitoba

Personal Information Consent and Disclaimer Form (Adults Only)

All questions marked with a star * must be filled out. This form is for adults only; please do not register clients under 18 years old.

Commitment to provide original immigration documents*
Immigrant Centre services are available only to newcomers who have a valid immigration document. These include permanent resident card, confirmation of permanent residence, record of landing, valid/unexpired study permit or work permit, unexpired visitor visa, or citizenship certificate. By signing your name below, you hereby confirm that you will bring your original immigration documents to Immigrant Centre once our offices reopen, to complete your registration. We will contact you once we are open again.
IC Client Number
Enter your IC Client number (leave blank if you haven't registered as an IC client yet).
Immigration Status*
Select your current immigration status from the list below.
- Permanent Resident - Non-Refugee
- Permanent Resident - Refugee
- Refugee Claimant
- Student Visa
- Convention Refugee
- Canadian Citizen (Naturalized)
- Canadian Citizen (Born in Canada)
- Visitor Visa
- Open Work Permit
- Closed Work Permit
UCI Number*
Enter your UCI number without spaces or dashes. You can find your UCI number on your immigration documents (work or study permit, PR card, COPR, citizenship certificate, or visitor visa).
NOTE: If you are a Canadian-born citizen, please enter the digit zero (0) below.
Date of Arrival to Canada*
Enter your date of arrival to Canada: year/month/day.
Date Format: YYYY slash MM slash DD
Full Name*
Enter your name as it appears on your immigration documents.
First Middle Last
Birth Date*
Enter your date of birth: year/month/day. NOTE: Registration is available to adults only; please do not register anyone ages 0 to 17.
Date Format: YYYY slash MM slash DD
Gender*
Select your gender from the list below.
- Female
- Male
- Other
Country of Birth*
Enter your country of birth.
Current Address in Manitoba*
Enter your current address in Manitoba.

Street Address Address Line 2 City Province Postal Code
Phone Number*
Enter your telephone number.
Email Address*
Enter your email address.
Enter Email Confirm Email
IRCC Contact*
Do you authorize Immigration, Refugees and Citizenship Canada to contact you for further research and consultation?
- Yes
- No
Personal Information Protection*
Under the Personal Information Protection and Electronic Documents Act (PIPEDA), the Government of Canada requires the Immigrant Centre to explain how we use your personal information. This act has been designed to protect you. We must also have your permission to use this information. By selecting Understood, you confirm that you read and understood this information.
Immigrant Centre Data Use*
Your personal information will be entered into our electronic data base and may be used, by any or all the services at the Immigrant Centre. Some of your information may be included in statistical information given to funders. You will not be identified by name. This information may also be used by the Immigrant Centre to contact you in the future. By selecting Understood below, you confirm that you have read the above, and understand which information is being collected and what it is being used for.
Disclaimer - Enter your Name Below*
DISCLAIMER: The Immigrant Centre is funded by Immigration Refugees & Citizenship Canada to provide information to ensure newcomers have ongoing, clear and up to date information. The Immigrant Centre offers general information which should not be viewed as legal advice or opinion. It is an individual’s own decision how to proceed with the information provided. By entering your name below, you confirm that you read and understood this disclaimer by Immigrant Centre.
Date*
Please enter today's date: year/month/day.
Date Format: YYYY slash MM slash DD
Phone
This field is for validation purposes and should be left unchanged.

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New clients: Online Disclaimer Form

Personal Information Consent and Disclaimer Form (Adults Only)