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Employment Service Participant Registration

Gezhtoojig Employment and Training

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Ontario

Ministry of Training,
Colleges and Universities

Employment Service
Participant Registration

EMPLOYMENT
ONTARIO

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Case Reference

Person Reference

Last Name

First Name

Middle Name/Nickname

Details

Gender

Male Female Undisclosed

Date of Birth

DD
MM
YYYY

Marital Status

Single Married (or equivalent) Undisclosed

Status in Canada

Canadian Citizen Permanent Resident Other:

Date Arrived in Canada

DD
MM
YYYY

Please complete if you wish to self-identify as a member of a designated group(s). Your response to this question is entirely voluntary and will not affect your eligibility. This information will be used by the Governments of Ontario and Canada for policy analysis and statistical purposes related to employment programs and services.

Newcomer

Person With Disability

Visible Minority

First Nations

Métis

Inuit

Preferred Language of Service

English French

Social Insurance No.

Address

Primary Mailing Address

Unit/Suite/Apt

Street Number and Name

City

Province

Postal Code

Alternate Mailing Address

Unit/Suite/Apt

Street Number and Name

City

Province

Postal Code

Contact

Primary Telephone

Home Mobile Other

Area Code

Tel. number

Ext.

Alternate Telephone

Home Mobile Other

Area Code

Tel. number

Ext.

Email Address

Education

Select your Highest Level of Education Completed

Grade 0 - 8

Grade 11

Certificate of Apprenticeship

Applied Degree

Grade 9

Grade 12 (or equivalent)

Journeyperson

Bachelor's Degree

Grade 10

OAC

Certificate/Diploma

Post Graduate

Institution of Highest Level of Education Completed

START Date

END Date

Type

Full-Time Part-Time

Country of Institution

Program Description

Additional Education

Some Apprenticeship Some College Some University

Institution of Additional Education (may or may not have been completed)

START Date

END Date

Type

Full-Time Part-Time

Country of Institution

Program Description

Employment
List your work experience below, including volunteer work. Start with the most recent job/volunteer activity.
Employment Type Paid Self Employed Unpaid Volunteer
Name of Employer			Job Title / Duties
Country of Employment		Employment START Date		Employment END Date	Service Provider Use Only NOC NAICS
Wage Amount $	Per Hour Week Bi-weekly Month Year			Employment Hours per Week
Reason for Leaving
Employment Type Paid Self Employed Unpaid Volunteer
Name of Employer			Job Title / Duties
Country of Employment		Employment START Date		Employment END Date	Service Provider Use Only NOC NAICS
Wage Amount $	Per Hour Week Bi-weekly Month Year			Employment Hours per Week
Reason for Leaving
Employment Type Paid Self Employed Unpaid Volunteer
Name of Employer			Job Title / Duties
Country of Employment		Employment START Date		Employment END Date	Service Provider Use Only NOC NAICS
Wage Amount $	Per Hour Week Bi-weekly Month Year			Employment Hours per Week
Reason for Leaving
Additional Information
How did you hear about this program?
What are your short-term employment/career goals?
What are your long-term employment/career goals
What types of work are you interested in doing? (List by order of preference)
Identify any necessary adjustments or accommodations at a job location, e.g. access and/or equipment needs, that may be required due to a health issue or disability
Have you applied for Employment Insurance Benefits in the past 52 weeks? Yes If “Yes”, where? No Unsure

Last Name	First Name			Case Reference	Person Reference
Client Summary (Service Provider Use Only)
Internationally Trained Professional Yes No
Labour force attachment Employed Unemployed Under-employed Self-employed Full-time Student Part-time Student
Credentials not recognized in Ontario Regulated trade certificate College diploma Regulated professional University degree High school diploma N/A
History of poor work retention? Yes No
Job search skills: Unknown Needs development Satisfactory Strength
Employment skills: Unknown Needs development Satisfactory Strength
Language skills: Unknown Needs development Satisfactory Strength
Recent job loss due to labour market change? Yes No
Employment Experience No work experience Worked in Canada Worked, but not in Canada
Source of Income Employment Insurance (EI) Ontario Disability Support Program (ODSP) Ontario Works (OW) Dependent of OW/ODSP Crown Ward Extended Care and Maintenance No Income Other, specify:
Highest Level of Education/Training Completed In Canada Outside Canada
Time out of school/work Less than 3 months 3 to 6 months 6 months to 12 months more than 12 months
Validation of OW/ODSP or EI status on file? Yes No Not Applicable			Validation of income on file (if Training Supports are provided)? Yes No Not Applicable
ES proof of eligibility has been reviewed and verified (age, legally entitled to work in Canada, etc.)? Yes No		Case Worker (First Name, Last Name)			Date
Notice of Collection and Consent
Your Service Provider delivers Employment Service under an agreement with the Ministry of Training, Colleges and Universities (Ministry) and is required to make its books and records available to the Ministry for inspection, investigation or audit. Your Service Provider is also required to report to the Ministry on the service it tailors and provides to you, your educational, training and employment progress and outcomes, and your satisfaction with the service you receive. The Ministry may collect relevant personal information from Canada if necessary to determine your eligibility for and the nature and level of Employment Insurance benefits and to monitor, assess and evaluate the effectiveness of Employment Service. Depending on the type of service or support you receive and any incentives available to your employer to hire you, the Ministry may also collect personal information indirectly from your employer. The Ministry will use your personal information to administer and finance Employment Service. Client information collected on this form may be recorded in the Ministry's Employment Ontario Information System (EOIS). Administration may include assessing service-provider performance, planning and evaluating Employment Service, conducting policy/statistical analysis and research, and promoting Employment Service. You may be contacted to request voluntary participation in surveys or public-relations campaigns. Employment Service is funded in part with funds provided by Canada under Part II of the Employment Insurance Act. The Ministry collects personal information in accordance with applicable Ontario and federal legislation. For more information, contact the Employment Ontario Hotline at 1-800-387-5656.
*By signing below, I give consent to the Ministry to indirectly collect, use and disclose my personal information for the purposes set out above.* Signature of Participant Date			*By signing below, I acknowledge that my Service Provider has explained its use and disclosure of my personal information for its purposes.* Signature of Participant Date

GEZHTOOJIG
EMPLOYMENT & TRAINING

PARTICIPANT REGISTRATION

Last Name:				First Name:
DETAILS
FIRST NATIONS Off-reserve On-reserve	METIS			INUIT			NON-STATUS
First Nation Band Affiliation (Community):					Band No. (10 digit)
Number of Dependents:	Age:	Age:	Age:	Age:	RESUME ATTACHED: YES NO
Driver's License: Y N Type:		Access to Transportation: Y N				Willingness to Relocate: Y N
SOURCE OF INCOME... You Must Select One
EI Employment Insurance	OW Ontario Works			ODSP Ontario Disability Support Program			Other, specify:
NOTICE OF COLLECTION AND CONSENT
I understand that Gezhtoojig Employment and Training may collect relevant information to monitor, access, and evaluate the effectiveness of Employment/Training Service and to administer and finance Employment/Training Service. Any exchange of personal information will be held confidential between all parties below:
Representative			Initial	Representative				Initial
• Employment Insurance				□ First Nation:
• Employment Ontario				□ Other LDM:
• Aboriginal Labour Force Development Circle				□ Employer:
• Union of Ontario Indians				□ Training Institution:
□ Other:				□ Ontario Disability Support Program
□ Other:				□ Ontario Works
I hereby grant permission to Gezhtoojig Employment and Training to collect, use and disclose my personal information when required, on an as needed basis for the purposes set out above. SIGNATURE OF PARTICIPANT: DD MM YYYY
CONSENT TO RECEIVE EMAIL UPDATES
To receive emails from Gezhtoojig about our program & services, employment opportunities and invitations to events please check one of the two options: YES I CONSENT or NO THANKS I CONSENT ... Email Address: SIGNATURE for Consent: Please note: To change your consent click on the “unsubscribe” button found at the bottom of our electronic messages.
SERVICE RATING As your Service Provider how would you rate Gezhtoojig Employment and Training's Services? Please rate on a scale of 1 to 5 (1 poor, 5 excellent): 1 2 3 4 5
BARRIERS TO EMPLOYMENT: (Do not fill out this Section) None Education Lack of Transportation Lack of Labour Force Attachment Economic Remoteness Lack of Work Experience Dependant Care Other Barrier Not Listed Lack of Marketable Skills Language Physical, Emotional or Mental Health

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Employment Service Participant Registration

Gezhtoojig Employment and Training

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