Intake Form

Last Name *

First Name *

Date of Birth *

YYYY-MM-DD

Gender Identity *Please Choose OneFemaleMaleAnotherNot Declared

Email *

Phone Number *

Residential Address or P.O. Box Number *

City or Town Name *

Province *

Position Gender landing:

Postal Code *

Alternative Contact Info

Employment Status at Intake *Please Choose OneEmployedSelf-EmployedUnemployed

Position Title *

If Unemployed please enter N/A or 0

Employer's Name *

If Unemployed please enter N/A or 0

Current Job Start Date (YYYY/MM/DD) *

Start date does not need to be precise; an estimated date is perfectly fine. If Unemployed please enter N/A or 0

Wage/Salary/Commission *

If Unemployed please enter N/A or 0

Hours Worked Per Week *

Hours do not need to be precise; an estimate is perfectly fine. If Unemployed please enter N/A or 0

Payment Frequency *Please Choose OneN/AHourlyDailyWeeklyBiweeklyMonthlyAnnually

Highest Level of Education Completed *Please Choose OneNot DeclaredNo Formal EducationGrade 1 to 11Grade 12/High School DiplomaModified High School DiplomaManture High School DiplomaG.E.D. or EquivalentLevel 1 ApprenticeshipLevel 2 ApprenticeshipLevel 3 ApprenticeshipLevel 4 ApprenticeshipLevel 5 ApprenticeshipJourneyperson CertificateRed Seal CertificateCollege/Vocational Education (1 to 3 years)University (1 to 3 years)College/Vocational CertificateCollege/Vocational DiplomaUniversity Certificate or DiplomaBachelor’s DegreeMaster’s DegreeDoctorate

Year Education Completed *

Are you currently receiving Employment Insurance (E.I.) benefits? *Please Choose OneYesNoNot DeclaredUnknown

Did you get an email from us about our services after applying for EI through Service Canada? *Please Choose OneYesNo

Are you currently receiving Provincial (EIA) or Band Income Assistance benefits? *Please Choose OneYesNoNot DeclaredUnknown

Income Assistance StatusPlease Choose OneActiveNon-activeNot Declared

Please answer if you are currently receiving Provincial (EIA) or Band Income Assistance benefits.

Indigenous Status *Please Choose OneNoneMétisInuitOn ReserveOff Reserve StatusNon-StatusNot Declared

Marital Status *Please Choose OneSingleMarried or EquivalentNot Declared

Dependents *Please Choose OneYesNoNot Declared

Individual(s) who live in the same household as me and for whom I have caregiving responsibilities. The dependent is a child(ren) (by birth, marriage, adoption or be a foster child) or an adult(s) dependent (e.g. an adult offspring with a disability)

If yes, number of dependents:

Disability *Please Choose OneYesNoNot Declared

I have long term or recurring impairment and consider myself to be disadvantaged in employment by reason of that impairment, or belief that an employer or potential employer is likely to consider me to be disadvantaged in employment by reason of that impairment.

Visible Minority *Please Choose OneYesNoNot Declared

Other than an Indigenous person, because of race or colour, I am considered a visible minority.

Immigrant/Refugee *Please Choose OneYesNoNot Declared

IMMIGRANT – I am a person with settled permanently in Canada from another country. An immigrant includes those who obtained a Canadian passport, who have been granted Citizenship or who have obtained Permanent Residence Status. REFUGEE – I am a person who was forced to flee from another country and settled in Canada.

If yes, year of landing:

How can we help you? *

• Job Search
• Resume
• Cover Letter
• Interview Skills
• Education & Training

Where or how did you hear about us? *

Any additional information you may have for the Regional Employment Resource Centre.

Please email your resume to admin@regionalemployment.ca *

• I already have sent my resume
• I will send right away
• I am unable to send

Consent *

• I have read and consented to the Privacy & Consent Form PDF provided on this page

Submit

Intake Form

An Employment Officer will contact you by phone/email to arrange an appointment time. Please check your junk/spam email folder as well incase our communication email ends up in there.

Alternatively, you can fill out the PDF below* and email it to admin@regionalemployment.ca

INTAKE FORM PDF VERSION

* Don’t forget to save the PDF before attaching it to your email or it will send as a blank form