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Intake Request Form

Your Personal Details

Current Residential Address

Immigration Related Information

This can be a Confirmation of Permanent Residence, a Work Permit, a Refugee Claimant document, a Permanent Resident Card, etc.

If uploading a Permanent Resident Card or other two-sided document, please ensure both sides are attached.
Drop files here or
Accepted file types: pdf, docx, doc, jpg, gif, tiff, Max. file size: 10 MB, Max. files: 1.

    Emergency Contact Information

    Additional Information

    Details of Family Members

    Would you like to register your family members so that they can also receive services with us?

    Member 1

    Member 2

    Member 3

    Member 4

    Member 5

    Member 6

    Consents and Confidentiality Statement

    Mail Consent

    I consent to your organization collecting, storing, and using my personal information for the purposes of providing services and communications related to events, workshops, and other relevant activities. I understand that appropriate security measures will be in place to protect my data from unauthorized access or misuse.

    I consent to the sharing of my personal information with trusted third-party partners of your organization solely for the purpose of delivering services and communications as described. I am aware that I have the right to withdraw my consent at any time, which may impact the services provided to me.

    Clear Signature
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    (204) 943-8765 |

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    Info@ircom.ca

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    IRCOM Ellen

    95 Ellen St, Winnipeg, Manitoba R3A 1S8 Canada

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    IRCOM Isabel

    215 Isabel St, Winnipeg, Manitoba R3A 1R5 Canada

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    IRCOM Learning Centre

    357 Bannatyne Ave, Winnipeg, Manitoba R3A 0Z3 Canada

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    CARMIS (Case Management Solution for Non-Profits)

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