Please fill out this form

First Name *

Last Name *

Phone *

Email *

Date of birth *

Address *

City *

Postal code *

Year of Immigration to Canada *

Country of Origin *

Do you have Active (EI) or had Reach back in the past 60 Months? *

Yes

Do you have a WorkBC Case Manager? *

How did you hear about this Program? *

Highest Level of Education

Bachelor's Degree

Year Attained

Discipline

Province / Country

Master's Degree

Year Attained (Master's)

Discipline (M)

Province / Country (Master's)

Doctorate

Year Attained (D)

Discipline (D)

Province / Country (D)

Other Education or Training

Emergency Contact

Full Name (EC)

Relationship

Emergency Contact

Consent *

I, authorize Progressive Intercultural Community Services Society (PICS), any other service providers, schools, and community agencies to disclose/exchange my personal information, including the usage of my photo and /or video in the following: (1) My eligibility for Employment Benefit Programs for the Ministry of Social Development, Province of British Columbia. (2) Information regarding my training, employment history, needs, and income support. (3) Information regarding my progress and follow-up results on my Action Plan. (4) Attendance at scheduled interviews and interventions at the above agencies. (5) Information regarding marketing of the program. The information disclosed/exchanged will be treated as confidential and will be used only by the agencies listed above in conjunction with your application for service.

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