Personal Information Full Name First Middle Last Status Card NumberCAFN Beneficiary? Yes No Date of Birth YYYY slash MM slash DD Social Insurance NumberEmail Phone 1Phone 2Male/Female Male Female Disabled/Not disabled Disabled Not disabled Are you on Employment Insurance? Yes No Have you collected EI in the Past 3 years? Yes No Current Source of Income Employed Fulltime Employed Part-time Self Employed Income (Social) Assistance No Income Other (WCB, Pension Income), etc Please specify Other income source Status Status on Settlement Land Status off Settlement Land Non Status Inuit Metis Have you applied to the Yukon Grant? Yes No Have you applied to Provincial Funding? Yes No Course Information What course/program will you be taking? What institute will you be attending? Will the institute provide you with a T2202A FORM FOR Taxation purposes? Yes No (You will/may be expected to pay for your education through your taxes) When does the Program start: YYYY slash MM slash DD When does the Program end: YYYY slash MM slash DD Accreditation sought: Trades Certificate Diploma degree Undergraduate Graduate Trades Level Part Time/Full Time Part Time Full Time – As defined by Institution (3 or more courses considered full time) Expected graduation year:# of years assistance is requested: Mailing Address This is your address is while you are in school Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code This is your permanent address when you are not going to school Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Family Marital Status Single, living w/parents Single-Unemployed Single-Employed Married w/ employed spouse Married w/ dependent spouse Number of Dependents01234 Dependant 1Name First Last AgeRelationship to you Dependant 2Name First Last AgeRelationship to you Dependant 3Name First Last AgeRelationship to you Dependant 4Name First Last AgeRelationship to you Educational History How many Educational Programs did you completed?0123 Educational Program 1Date attended from MM slash DD slash YYYY Date attended to MM slash DD slash YYYY Name of institution Program Year Completed Educational Program 2Date attended from MM slash DD slash YYYY Date attended to MM slash DD slash YYYY Name of institution Program Year Completed Educational Program 3Date attended from MM slash DD slash YYYY Date attended to MM slash DD slash YYYY Name of institution Program Year CompletedDid you graduate from High School? Yes No What Year? Employment HistoryHow many jobs did you have0123 Job 1 Information Name & Address of EmployerStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Job Title Name of Supervisor First Last Supervisor Phone Job 2 Information Name & Address of EmployerStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Job Title Name of Supervisor First Last Supervisor Phone Job 3 Information Name & Address of EmployerStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Job Title Name of Supervisor First Last Supervisor PhoneHave you applied for other sources of funding? Yes No From where? Have you applied to YTG Yukon Grant? Yes No TRAINEE DECLARATION I certify that the information above is true, correct and complete in every respect and I understand I may be subject to verification by CAFN or its representatives, I will report to CAFN as soon as possible, if there are changes in the information, I am aware legal action can be taken against me for making false statements or failing to inform CAFN of changes to the information affecting my entitlement to allowances and/or Employment Insurance benefits. I am aware that I may be disqualified from receiving benefits should I voluntary or involuntarily exit the course, or not attend on a regular basis. I hereby declare that I acknowledge the terms and conditions set out in this contract and agree that in the event that I choose not to adhere to one or more of the following, I may be exempted from future funding. 1. I am responsible to reimburse CAFN for training costs or allowances, on a per diem basis, should I voluntarily or involuntarily exit the course, or not attend on a regular basis. 2. I will provide receipts to CAFN for pre-approved training related purchases. 3. I a responsible for any costs incurred in excess of the agreed upon amount. 4. I am responsible to provide CAFN with a written evaluation of the training upon completion. I will save CAFN harmless from and against all claims, losses, damages, costs and expenses related to any injury or death of a person, or loss or damages to property caused or alleged to be caused by this training initiative and that all necessary liability and life insurance shall be maintained by me for the duration of this activity. TRAINEE WAIVER: I agree and authorise that information related to this training may be shared amongst participating Provincial Ministries, Federal Departments and Public /Private Training Institutions identified as being a stakeholder. When the option to appeal is being exercised, the written appeal is to be forwarded to the CAFN Manager of Education, Employment & Training (Attention: APPEALS) Please ask for an APPEALS FORM. Signature of ClientDate MM slash DD slash YYYY Note: Applications must be completed in full. Failure to do so will delay application approval. FOR OFFICE USE ONLY Reviewed by: Date MM slash DD slash YYYY Approved: Date MM slash DD slash YYYY Δ