NLMA Parental Leave Allowance
Application Form

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Instructions Submit this form initially to apply for the NLMA Parental Leave Allowance. It will be used to determine your eligibility and enrolment. Note, once approved you must submit the separate Report Form regularly (biweekly recommended, unless you use the special version for EI recipients) to actually receive the allowance.

Applicant

Name

NLMA Number

Co-Parent Full Name

Child Full Name

MPA
(Medical Practice Associates)

Yes No

MCP Provider Number

Leave

Reason

Adoption
Birth (Self)
 
Birth (Spouse)
Birth (Surrogate)

Birth/Placement Date
(Proof may be requested; DD/MM/YY)

 

Leave Start Date
(DD/MM/YY)

 
(Date you consider yourself off for parental or medical reasons; not necessarily date NLMA Parental Leave Allowance begins)

Leave End Date
(DD/MM/YY)

 

Other Anticipated
Income Sources
(Check all that apply; proof may be requested)

Fee for service
Academic
 
Employment Insurance (EI) benefits
Other employment income
 
None
 

Notes

Comments

Signature

Consent

I authorize the NLMA to verify my information, income and otherwise, with third-parties, including the Newfoundland and Labrador Medical Care Plan (MCP), for any period I am in receipt of benefits from the NLMA Parental Leave Allowance. I understand this verification may be made at any time and is not limited to my leave period.


Assistance For assistance, please contact J. David Mitchell, Director, Administration & Membership at (709) 726-7424 (301), (800) 563-2003 (301) or dmitchell@nlma.nl.ca.

Newfoundland and Labrador Medical Association
NLMA House, 164 MacDonald Dr., St. John's, NL, Canada, A1A 4B3
Telephone (709) 726-7424 | Toll Free (800) 563-2003 | Fax (709) 726-7525
E-mail nlma@nlma.nl.ca | Web www.nlma.nl.ca