Information Protected

(For office use only) Date entered: __________________________ Assigned Cns: _________________________ Time: ____________ by: _________________________________

APPLICATION FORM FOR CONSIDERATION OF RECEIVING EMPLOYMENT INSURANCE (EI) BENEFITS WHILE IN FULL-TIME UNIVERSITY STUDIES THROUGH THE DEPARTMENT OF POSTSECONDARY EDUCATION, TRAINING AND LABOUR (PETL)
CETTE FICHE DINFORMATION EST DISPONIBLE EN FRANAIS

Have you received EI benefits in the last year while attending university full time? Yes (Please contact Gisle Clment by e-mail at Gisele.Clement@gnb.ca or by telephone at 506-856-2321.) No (please continue to complete this application). Please respond to the following questions: (1) Do you have a New Brunswick Medicare card : yes No If yes, please provide your Medicare number : ___________________ (2) Are you in the last 2 years of your university program? Yes No If you have answered NO to any of the above questions , you DO NOT qualify for our program. If you answered YES to all the above questions, please continue to complete this application form. Did you attend a full-time university program this last academic year (2010-2011)? No - please visit the PETL office nearest your permanent residence. Yes - please continue to complete this application form. Please attach a copy of your Medicare card, as well as Proof of Enrolment in a fulltime program from your university and ensure that your estimated graduation date and the number of credits remaining to complete your program is included on the Proof of Enrolment. YOUR APPLICATION WILL NOT BE CONSIDERED IF THIS INFORMATION IS NOT PROVIDED.
Modified April 2011 1

Information Protected

A. Client Data Name _______________________________________________________________ SIN ________ ________ ________ Address_________________________________________ City __________________ Province ________________ Postal code ______ ______ ______ _____ ________

Home telephone ______ _____ ________ other phone #

Email address ____________________________________________ Male Female _______ Month Single ________ Year Married or equivalent How many dependants ______ No

Date of birth ______ Day Marital Status:

Are you member of a First Nations group? Yes Do you have a disability? Yes Citizenship: Canadian Citizen No

Permanent Resident

Other

_______________

What is your source of income? Social Assistance Other Please specify:____________

Employment Insurance

How did you find out about our services? ______________________________________ Modified April 2011 2

Information Protected

C- Education or Training

Please indicate Level of High School Completed

Highest High School Grade Completed _______ GED Adult High School diploma diploma diploma year obtained________ year obtained ________ year obtained ________

Please indicate current Post-Secondary Study

University degree Which University are you attending ______________________________ Degree/Diploma Title ________________________________________________ Full Time Student Part Time Student

What is the length of your program _______________________ What study year are you entering: 1st 2nd 3rd 4th 5th or other : ______

In what month/year will you obtain this Degree ________________________

Previous Post-Secondary Program Attended

University (program title) _________________________ Completed Correspondence Diploma (program title) _________________ Completed College Diploma (program title) ____________________ Completed Other course completed (course title___________________________________)
Year, incomplete

Year______ Year______ Year_____

Year, incomplete

Year, incomplete

Year______

Modified April 2011

Information Protected D-Work History Last 3 Employers 1. Name of Employer / Company _________________________________ Job Title _________________________________________ Employment period from _____________ to _____________ Gross Wages Received Hour $_______ (or) Week $_______ (or) Annual $________ Reason for leaving _________________________________________ (**refer to list at the bottom of the page)

2.

Name of Employer / Company _________________________________ Job Title _________________________________________ Employment period from _____________ to _____________ Gross Wages Received Hour $_______ (or) Week $_______ (or) Annual $________ Reason for leaving _________________________________________

3.

Name of Employer / Company _________________________________ Job Title _________________________________________ Employment period from _____________ to _____________ Gross Wages Received Hour $_______ (or) Week $_______ (or) Annual $________ Reason for leaving _________________________________________

Possible reason for leaving your job A - Shortage of work F - Maternity or parental leave C - Back to school I - Relocated D - Sick leave M - Dismissed E - Quit K - Other (explain) Thank you for completing this information.

Modified April 2011