Intake & Needs Assessment Form

* CNA Participating Bands (Please select Band you are registered with)

* First Name:

* Last Name:

* Social Insurance Number:

* Band Status Number:

* Date of Birth:

* Address:

* Phone:

* Email:

* Are you: Employed
Unemployed

* Are you: Actively on EI Benefits
Been on EI Benefits in the past five years
Social Assistance
Not Applicable

* Are you currently looking for work: Yes
No

* What type of work are you looking for:

* Do you want full-time or part-time work: Full-time
Part-time
No preference

* What hours do you want to work: Days
Evenings
Weekends
No preference

* Are you willing to relocate for employment: Yes
No

* Do you have a resume: Yes
No

Upload resume: Clear

* Do you have a cover letter: Yes
No

Upload cover letter: Clear

* Are you participating in other programs: (Please check all that apply. Hold down shift key for multiple sections)

* Are you interested in participating in other programs: (Please check all that apply. Hold down shift key for multiple sections)

* Do you have a disability that may limit your participation for employment or training: Yes
No

* Do you require any accommodations: Yes
No

* Education & Training: (Please check all that apply. Hold down shift key for multiple sections)

Please list education and training completed:

* Have you previously taken training with the CNA: Yes
No

If yes, what training did you take:

* Do you have a driver's licence: Yes
No

Licence class & expiry date:

* If you do not have a driver's licence, are you able to get one: Yes
No

Workplace Certifications: (Please check all that apply. Hold down shift key for multiple sections)

Other Certifications:

* Job Search Challenges: (Please check all that apply. Hold down shift key for multiple sections)

Job Search What's Working: (Please check all that apply. Hold down shift key for multiple sections)

Welcome Members!