| NETES

(CAHRD) CENTRE FOR ABORIGINAL HUMAN RESOURCE DEVELOPMENT INC.
304-181 Higgins Avenue, Winnipeg, Manitoba R3B 3G1
Telephone: (204) 989-7110 Facsimile: (204) 989-7113
WWW.CAHRD.ORG

“Applicants to CAHRD’s ISET program must complete this form with all requested information. Your information will be kept confidential in accordance with Canadian privacy laws upon completion and submission. The information provided is utilized to determine your eligibility for the ISET program and the funding you may receive.”

CLIENT INFORMATION:

Last Name *

Maiden Name

First Name *

Date of Birth *

Middle Name(s)

Social Insurance Number *

CONTACT INFORMATION:

Address

Email *

City *

Phone *

Province *

How Long Have You Lived In Winnipeg *

Postal Code *

Move Date

SELF-DECLARATION OF INDIGENOUS ANCESTRY:

Self-Declaration of Indigenous Ancestry

MARITAL STATUS / GENDER / DEPENDANTS:

Marital Status *

Gender: *

*Other: Please Indicate

Dependants (if applicable) *

DISABILITY:

Do you have a disability?

Yes
No

SOURCE OF INCOME OR FUNDING:

SOURCE OF INCOME OR FUNDING (check all that apply):

Amount of Monthly Income or Living Allowance:

DRIVING INFORMATION:

REFERRAL SOURCE:

How did you hear about our services? *

Where do you want to be in 5 years (education/training/other?)

PRIMARY/SECONDARY EDUCATION:

Name of Last School Attended

Location

Date / Time

Grade 12

Grade 12 Diploma
GED

Highest Grade Level Completed *

Reason(s) for leaving if you did not graduate?

POST SECONDARY EDUCATION:

Last Post-Secondary School Attended

Location

Date / Time

EMPLOYMENT HISTORY:

Employer

Employer1

Employer2

Employer3

Employer4

Employer5

Position

Position1

Position2

Position3

Position4

Position5

Start Date (mm/dd/yyyy)

Start Date1

Start Date2

Start Date3

Start Date4

Start Date5

End Date (mm/dd/yyyy)

End Date1

End Date2

End Date3

End Date4

End Date5

REGISTRATION PURPOSE:

ES

Employment Services

ACC

Aboriginal Community Campus

NCAT

Neeginan College of Applied Technology

ABORIGINAL COMMUNITY CAMPUS:

NEEGINAN COLLEGE OF APPLIED TECHNOLOGY

CLIENT AUTHORIZATION:

I hereby authorize (CAHRD) Centre for Aboriginal Human Resource Development Inc. to exchange employment related information with employers and/or education/training institutes on my behalf. I acknowledge and consent to the sharing of Personal Information with Employment and Social Development Canada (ESDC) and the Province of Manitoba and their agents. I acknowledge having been informed that the above noted information is protected and will be stored in a secure manner. I am aware that, under the Privacy Act of Canada, I am entitled access to this information. I also agree that CAHRD may contact me in the future for updates on my employment and education status. *

Clear Signature