COMMUNITY FUTURES DEVELOPMENT CORPORATION OF

CENTRAL INTERIOR FIRST NATIONS

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APPLICATION FORM
Phone: (250) 828-9727 Fax (250) 828-9972

APPLICANT PROFILE

DATE:_____________________

Name: ________________________________________________________________________________
Address:_____________________________

City:_________________ Postal Code: ____________

Telephone:___________________________

Cell: ______________________________________

Messages ___________________________

Email:______________________________________

Date of Birth: d/m/y_____________________

S.I.N. #: __________________________________

First Nation On-Reserve

First Nation Off-Reserve

Mtis

Other

Band/Mtis, Inuit Band Name & Number: _____________________________________________________

Labour Force Attached & Current Income
Employed

Unemployed

S elf-employed

Student

Pension

Employment Insurance

Provincial Social Assistance

Band Social Assistance

Other (Specify)______________ _______________________

Financial Assistance Worker:___________________

Workers Compensation

Phone # _________________________________

Receiving Benefits Since: ______________________________________________________

Do you need Daycare? Yes

No

Transportation? Ye s

No

Optional Persons with Disabilities

Agility

Hearing

Learning

Visual

Developmental

Mental Health

Intellectual

Motor Skills

Speaking

Other (please specify) _____________

Job Search
Last day worked________________________________, Position_______________________________
Reason for leaving_____________________________________________________________________
Are you currently looking for work?
Yes

Where/What kind of work? ________________________________________________________

No

If no, why not? ___________________________________________________________________

Current Resume Attached? Yes

No

In Progress _________________________________

Do any of the following difficulties apply?

_____ lack of specific skills, training, or education

_____ lack of work experience

_____ require retraining assistance

_____ unsure of career possibilities

_____ few jobs available in your field

_____ other

Declaration & Permission

I declare that the statements made by me in my application to Community Futures Development Corporation of Central
Interior First Nations (CFDC of CIFN), Preparation for Employment Training Program are true and complete to the best of
my knowledge. I understand that if any of these statements are found to be untrue, this application may be rejected. I
give permission to the service providers, and government staff to share information relevant to my participation in the
Preparation for Employment Training Program, and to contact previous or present employers regarding my skills and
abilities.

___________________________________
Signature

___________________________________
Print Name