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How did you find out about the program?
E.D.O. Referral: (Counselor Name)
Personal Referral: (Name)
Other:
HRSDC Hand Out
Family Name:
First Name:
Address:
City:
Province:
Postal Code:
Home Phone:
Cell Phone:
Email address:
Birth date:
S.I.N.:
Unemployed since:
Gender: M
F
Are you receiving any type of income benefit:
No
Employment Insurance
Applied
CPP
Private Insurance
Social Assistance
Settlement Support
Workers Compensation
Other
Type of work in previous two jobs:
Highest level of education completed:
Field of Study:
Have you taken any government funded programs
in the past 6 months? Y
N
If yes, which ones?
Audible/Visible Minority:
Youth (19-29):
Disabled:
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Sign up for the
Success @ Work
program!
A FREE government sponsored course designed for people in work transition.
The Government of Canada has contributed funding to this initiative
Contact Us Toll Free
1.888.371.5777
Local in USA:
360.332.6292
Local in Canada
604.854.6292
By fax:
604.854.5629
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