At Work/Au Travail Employment Program

Name and Pronouns(Required)

Date of Birth(Required)

Health Card Number (10 digits)(Required)

Version Code (2 letters)(Required)

Social Insurance Number (SIN)(Required)

Please note: At Work/Au Travail Employment Program requires a physical copy of your SIN card to determine eligibility. SIN Cards can be obtained in-person or online from Service Canada using one primary identification document (i.e. birth certificate) and one secondary identification document (i.e. driver’s license, passport, provincial ID, etc.).

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (Primary)(Required)

Phone (Alternate)

Can we leave a messge?(Required)

Voicemail

Text message

Do not leave a message

Email(Required)

Current employment status(Required)

Please check all the apply

Employed 20+ hours/week

Employed under 20 hours/week

Job change/crisis

Unemployed

Employment Skills Education

Volunteer work

Self-employeed

Name of Referrer (if not self-referring)

First Last

Phone

Relationship to client

Client Consent Gained

Yes

Is there anything else you’d like us to know before we get in touch?

Date of Referral(Required)

At Work/ Au Travail Employment Form