First Name:

Last Name:

Middle Name:

Gender:

female 
male    

Birth date (year/month/day):

Phone:

Alternate Phone:

Fax Number:

Address:

City, Province:

Postal Code:

E-mail:

Are you legally entitled to work in Canada: Yes   No

Are you currently attending school?  Yes      No

Name and Address of School:

Expected Graduation Date:

None

Ontario Disability Support Program

Workplace Safety and Insurance Board

Canada Pension Plan

Employment Insurance/        
Employment Insurance Exhausted

Have you received Employment Insurance in the past? If yes, when did you receive it?

 

Other (Specify):
 

What is your disability:

Other (Specify):

Please explain your disability/barrier:
 

What kind of work would you like?
 

Who told you about Leads?

Other Agency (specify):

 

School (specify):

 

Other (specify):

 

Have you used our service before?      Yes      No