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CSETS Participant Information Form
CSETS Participant Information Form
docmedia
2021-11-03T21:47:09-07:00
CSETS PIF Form
Name
(Required)
First
Middle Initial
Last
Date of Birth
(Required)
Month
Day
Year
Social Insurance Number
(Required)
Gender
(Required)
Male
Female
Other
Unspecified
Are you a Person with a Disability?
(Required)
No
Yes
What is your Disability?
(Required)
Unspecified Disability
Developmental
Learning
Psychiatric
Physical
Combination
Speech
Hearing
Visual
Marital Status
(Required)
Married or Equivalent
Single
Divorced
Widowed
Separated
Number of Dependents
(Required)
Aboriginal Type
(Required)
Choose One
Registered Aboriginal
Non-Status Aboriginal
Metis
Inuit
Unspecified
Status Number
(Required)
Band
(Required)
On Reserve Status
(Required)
Yes
No
Language Spoken
(Required)
English
Aboriginal Language
French
Other
What is your current situation? (Check all that apply)
(Required)
Employed
In School
Unemployed
Other
Self-Employed
Job Title
(Required)
Employer
(Required)
Grade
(Required)
School Name
(Required)
Job Title
(Required)
Are you Returning to School?
(Required)
Yes
No
School Name
(Required)
Grade / Year Level
(Required)
Program
(Required)
Start Date
(Required)
MM slash DD slash YYYY
End Date
(Required)
MM slash DD slash YYYY
Highest Level of Education
(Required)
No Formal Education
Grade 1 to Grade 5
Grade 6 to Grade 8
Grade 9
Level I (Grade 10)
Level II (Grade 11)
Level III (Grade 12)
High School Graduate
Year Attained
(Required)
Write N/A if not applicable
Post-Secondary
(Required)
No Post Secondary
Non-University Certificate or Diploma such as Trades Certificate
1 Year Diploma/Certificate
2 Year Diploma/Certificate
3 Year Diploma/Certificate
1 Year No Diploma/Certificate
2 Year No Diploma/Certificate
3 Year No Diploma/Certificate
University - Bachelor's Degree
University -Master's Degree
Doctorate
Year Attained
(Required)
Write N/A if not applicable.
Education Province
(Required)
Primary Phone
(Required)
Alternate Phone
Email
(Required)
Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
What is your Job/Career interest?
(Required)
Are you a Social Assistant Recipient?
(Required)
Yes
No
Current EI Claimaint
(Required)
Yes
No
Within the last 5 years?
(Required)
Yes
No
Barriers to Employment
(Required)
None
Lack of Labour Force Attachment
Lack of Work Experience
Lack of Transportation
Remoteness
Language
Education
Economic
Dependent care
Lack of Marketable skills
Physical/mental health
Other barriers
Other Barriers
(Required)
My signature below means:
I have answered all questions on this form and certify that all information I have provided is complete accurate and true. I understand Coast Salish Employment & Training Society and/or its Member Organization receives funding for this program from the federal government as a result of the Canada Indigenous Skills & Employment Training Strategy (ISETS) Agreement Holder.
I understand that the information provided on this form or that has been collected about me during my participation in this program will be forwarded to the HRSDC/Service Canada for evaluation purposes and reporting requirements as per signed ISETS Agreement.
I consent to being contacted by HRSDC/Service Canada (or its agent) and up to 12 months after completion of my participation in this program for the purpose of program evaluation. I consent to the information I have provided on this form being shared with potential employers for assessment in job readiness.
I understand that once signed, this document becomes a protected document under the Personal Information Protection and Electronic Documents Act or similar applicable provincial legislation.
Collection and Use of Information.
All information is collected pursuant to section 26() of the Freedom of Information and Protection of Privacy Act. The information provided will be used for administrative and evaluation purposes of this program.
Signature
Client Name
First
Last
Date Signed
MM slash DD slash YYYY
Δ
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