PANIER DE NOËL – Coopération Intégration Canada

Christmas basket

Vous habitez à Ottawa et vous souhaitez bénéficier d’un panier de Noël gratuit ou d’un chèque cadeau échangeable ? Ce programme est pour vous !

Contactez-nous avant et remplissez le formulaire au plus tard le 19 novembre 2024 à 23h59. Nous serons heureux de vous servir !

Program funded by:

This program is only open during Christmas

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First Name *

Last Name *

Date de naissance *

Votre Sexe? *

Masculin
Féminin
other

Phone Number *

Email *

Preferred communication language *

French
English

Are you covered by the low income threshold standard? Check the box that corresponds to the range of your annual income, based on the size of your family *

1 person in the family? After-tax family income less than or equal to $24,347
2 persons in family? Family income after taxes less than or equal to $29,632
3 persons as a family? After-tax family income less than or equal to $36,898
4 persons in family? Family income after taxes less than or equal to $29,632
5 persons as a family? After-tax family income less than or equal to $52,418
6 persons in your family? After-tax family income less than or equal to $58,133
7 persons or more as a family? After-tax family income less than or equal to $63,848

Is the client's address a co-op or apartment building? *

If yes, please enter the alarm or bell number here:

Is it a shelter or a shared apartment? *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Does the client have a spouse or partner? *

un(e) section tous

If yes, please enter their email

Last Name

If yes, please enter their phone number

Number of Kids (0 to 17 years old) *

Please enter the name(s), gender(s) and age(s) of all children in the household

Number of adults (18 to 54 years) *

Please enter the name(s), gender(s) and age(ies) of all seniors in the household: (If applicable – Include the client listed in the primary information section):

Total number of seniors (55 years and over) *

Please enter the name(s), gender(s) and age(ies) of all seniors in the household: (If applicable – Include the client listed in the primary information section):

Other information:

Would you like to be contacted for other services offered by CICAN? *

By filling out this form, you agree to share your data with us. All data collected will be used only for the purpose of this booking and will not be shared with any third party unless you explicitly authorize it.