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Champagne and Aishihik First Nation Yukon Canada
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Personal Information
Full Name
CAFN Beneficiary?
YYYY slash MM slash DD
Male/Female
Disabled/Not disabled
Are you on Employment Insurance?
Have you collected EI in the Past 3 years?
Current Source of Income
Status
Have you applied to the Yukon Grant?
Have you applied to Provincial Funding?

Course Information
Will the institute provide you with a T2202A FORM FOR Taxation purposes?

(You will/may be expected to pay for your education through your taxes)

YYYY slash MM slash DD
YYYY slash MM slash DD
Accreditation sought:
Part Time/Full Time

Mailing Address
This is your address is while you are in school
This is your permanent address when you are not going to school

Family
Marital Status

Dependant 1

Name

Dependant 2

Name

Dependant 3

Name

Dependant 4

Name

Educational History

Educational Program 1

MM slash DD slash YYYY
MM slash DD slash YYYY

Educational Program 2

MM slash DD slash YYYY
MM slash DD slash YYYY

Educational Program 3

MM slash DD slash YYYY
MM slash DD slash YYYY
Did you graduate from High School?

Employment History

Job 1 Information

MM slash DD slash YYYY
MM slash DD slash YYYY
Name of Supervisor

Job 2 Information

MM slash DD slash YYYY
MM slash DD slash YYYY
Name of Supervisor

Job 3 Information

MM slash DD slash YYYY
MM slash DD slash YYYY
Name of Supervisor

Have you applied for other sources of funding?
Have you applied to YTG Yukon Grant?

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.

MM slash DD slash YYYY

Note: Applications must be completed in full. Failure to do so will delay application approval.


FOR OFFICE USE ONLY

MM slash DD slash YYYY
MM slash DD slash YYYY

Champagne & Aishihik First Nation Logo

HAINES JUNCTION OFFICE

#1 Allen Place, P.O. Box 5310
Haines Junction, YT Y0B 1L0
867-634-4200

WHITEHORSE OFFICE

304 Jarvis Street
Whitehorse, YT Y1A 2H2
867-456-6888

COMMUNITY BUILDINGS

Takhini Hall 867-667-6701
Da Ku Store 867-634-3307
Youth Center 867-634-2012
Mun Kų 867-634-7001
Champagne Hall 867-634-2336
Klukshu Hall 867-634-2342

contactus@cafn.ca

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