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Personal information on this form is collected under section 31(c) of the Freedom of Information and Protection of Privacy Act R.S.P.E.I. 1988, c. F-15.01 as it relates directly to and is necessary for the administration of the PEI Employment Development Agency’s programs and will be used for determining program eligibility and maintaining program data for statistical purposes. If you have any questions about this collection of personal information, you may contact the PEI Employment Development Agency, 548 Main Street, PO Box 1180, Montague, PE, C0A 1R0, Telephone (902) 838-0910.

Fields marked with a red star (*) are mandatory.

Employment Interests
Preferred program(s), type of work or career goal(s)
1: *
2:
3:
What areas in the Province are you willing to work?
1: *
2:
3:
Are you a resident of PEI?: * (Island students attending off-Island schools, respond, Yes)	Yes No
What employment program(s) are you interested?: (Check all that apply)	PEI employment creation programs: i.e. Jobs for Youth Program Seasonal employment with PEI Government Departments: i.e. Transportation & Infrastructure Renewal, Tourism & Culture
Personal Information
Last Name: *
First Name: *
Initial: *
Civic Address: *
Postal Code: *
Rural Route/PO Box: *
Community Name: *
Province: *
Telephone: *
Telephone (other):
Email Address:
The PEI Human Rights Commission has approved these questions for statistical use to determine eligibility for targeted employment programs
Gender: *	Male Female
Date of Birth: Year: *
Month: *
Day: *
Your voluntary response to the following questions will assist us in determining our diversity and equity goals.
Are you::	An aboriginal Person
Are you::	A person with a disability?
Please Specify:
Are you:	A member of a Visible Minority?
Please Specify:
Emergency Contact:
Address:
Telephone:
Education
Are you currently enrolled in full time studies?: *	Yes No
Will you be returning to school full time in the current year?: *	Yes No Undecided
If Undecided, state reason:
Highest education currently enrolled and completed by Summer?: *	School College University
If University, check all that apply:	BA MA PHD Diploma
School/G.E.D. - Grade:
College - Academic Year:
College Program:
University - Academic Year:
Faculty:
Major(s):
Skills/Work Experience/Volunteer Work
Beginning with your most recent employment, list employer, type of work and dates worked: * (You may attach your resume)
Attach Resume: (Optional)
Languages Spoken: *	English French Other (Specify below)
Other:
Typing (w.p.m):
Clerical and Computer Skills
Check all that apply:	Computer Programmer Computer Technician Data Entry Word Processing Internet/Email Spreadsheet Web Design Admin Support Bookkeeping Clerk/Cashier
Licensing, Trades and Course Certificates:
Check all that apply:	First Aid Lifeguard WHMIS CPR Pesticides Security Chainsaw Flagging
Valid Driver's License?:	Yes No
Class?:
Heavy Equipment Operator?:	Yes No
Class?:
Trade Certificate (1)?:
Trade Certificate (2)?:
Vehicle Access:	Car Truck/Van Motorcycle
Other Related Skills
Check all that apply:	Health/Seniors Support Worker Responsible Beverage Server Forestry Worker Environment Support Trail Maintenance Golf Course Worker Highway Maintenance Janitorial Worker Super Host Program Tourism Support
Declaration In submitting this information I certify that the foregoin statments made by me are true in substance. I authorize the PEI Employment Development Agency and the PEI Department of Fisheries, Aquaculture and Rural Development to verify the above information, to obtain or release information pertaining to my suitability for employment and/or to obtain or release confidential information on employment insurance eligibility to be used ony for the purpose of providing employment opportunities.
Date:	(MM/DD/YYYY)

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