GDI TRAINING & EMPLOYMENT PATHWAYS FOR ENTREPRENEURSHIP
CLIENT SCREENING PACKAGE
DOCUMENT CHECKLIST
The Pathways for Entrepreneurship (Pathways) assists Métis clients to prepare for, create, maintain, and/or expand a personal business with a goal of increasing Métis entrepreneurship in Saskatchewan.
To avoid delays in processing your application, please send the following documents and completed Client Screening Package via email to: [email protected]:
☐ Saskatchewan Health Card
☐ Dependent(s) Health Card(s)
☐ Verification of Social Insurance Number
(ex. SIN card, Notice of Assessment or other Canada Revenue Documents displaying your SIN,
document from Government agency displaying both your SIN and name)
(or signed Direct Deposit form printed from your bank’s online banking system)
☐ Daycare Verification Form (included) completed by your provider (if applicable)
☐ Signed Client Consent and Release Form (included)
☐ Copy of Business Plan (if available)
☐ Letters of offer or proof of financial commitment to your project (if available)
☐ Articles of Incorporation (if available/applicable)
☐ Copy of Journeyman's Certificate (if applicable)
☐ Copy of Resume
☐ Course Outline/Description or Program Ad (if available/applicable)
☐ GDITE Direct Deposit Application (included) with Void Cheque or Teller Stamp
Package Requirements (to be completed by your Employment Counsellor):
☐ Funding Request Summary
☐ Contract Purchase Notice
☐ EI Inquiry
☐ Counsel to Quit (if client is employed)
☐ Action Plan and Assessment
Pride. Perseverance. Possibilities.
GDI TRAINING & EMPLOYMENT PATHWAYS FOR ENTREPRENEURSHIP
CLIENT SCREENING PACKAGE
SECTION 1 – PERSONAL IDENTIFICATION
Middle Initial:
Province: Postal Code:
Gender:
Cell Phone Number:
Métis Nation – Saskatchewan Region:
Social Insurance Number:
First Name:
Last Name:
Email Address:
Mailing Address:
City:
Home Phone Number:
Alternate Number:
Birth Date: SK Health Card Number:
Do you have a disability?
Marital Status:
No Yes (ex: mobility, learning, mental health, hearing, vision, addictions)
*If yes, do you require training supports to accommodate your disability? No Yes
Language Spoken (check all that apply): English French Indigenous Languages Other
Have you applied for, or are in receipt of:
Social Assistance
Student Loans
Workers Compensation
Transitional Employment Allowance
Provincial Training Allowance
Employment Insurance*
*Date Applied for EI:
SECTION 2 – DEPENDENT INFORMATION
Please list all dependent children under the age of 18. Indicate whether the dependent requires child care, and whether daycare is subsidized.
Yes
Yes
Yes
No
No
No
Yes No
Are you requesting support for daycare expenses from GDI? Yes No
ex: 09-Sep-1998
Yes No
YesYes NoNo
ex: 05-Sep-2016
Screening Date:
GDITE Client ID:
Middle Initial:
SIN Verified
Pride. Perseverance. Possibilities.
SECTION 3 - EDUCATION HISTORY
K-12 ABE GED
Year completed:
SECTION 4 – EMPLOYMENT HISTORY
Yes* No
Year completed:Highest K-12 level attained:
In which program did you attain your highest level?
Highest Post-Secondary level completed:
Are you currently employed?
*If yes, please list your currently employment
If you have had previous training, please explain why you are not employed in a position to utilize your skills.
If you had previous training, please explain how it was funded.
Why did you leave your last job?
Please detail your work experience:
June 2019 Pride. Perseverance. Possibilities.
SECTION 6 – DECLARATION AND SIGNATURE – MANDATORY
I declare that the provided information is true and correct, and that I will provide the required supporting documentation to Gabriel Dumont Institute Training & Employment. I authorize the Clarence Campeau Development Fund to request a credit report and provide the information to Gabrield Dumont Institute. I hereby apply for GDI Training & Employment programming.
I hereby self-declare that I am: Métis First Nations Inuit
Client Signature Date
SECTION 5 – SERVICES SOUGHT
Why are you applying for this program?
What Services are you currently seeking through this program?
Start a New Business Acquire an Existing Business
Maintain an Existing Business Expand an Existing Business
Mentorship
What type of mentor are you hoping to be matched with?
Entrepreneurship Training
Which course are you interested in?
What are the costs?
Training Specific to your Business
Which course are you interested in?
What are the costs?
Blue Seal Training
Which course are you interested in?
What are the costs?
Business Plan Assistance
What stage of business planning are you at?
Professional Services/Consulting
What type of professional are you seeking services from?
Self-Employment Transition Allowance
When did you become fully self-employed?
June 2019 Pride. Perseverance. Possibilities.
SECTION 7 – BUSINESS INFORMATION (PLEASE COMPLETE ALL APPLICABLE FIELDS IF YOU ARE AN EXISTING BUSINESS OWNER)
Your business is:
If registered through ISC, please provide your ISC registry number:
CRA Business Number (if known):
WCB number (if known):
If you are an incorporated business or partnership, you are required to provide Articles of Incorporation or a Partnership Agreement with your application.
As an existing business owner, what percentage (%) of the business do you own?
Please list the business owners, positions held, respective percentages owned, and if the owner identifies as Métis):
Province: Postal Code:
Full Legal or Incorporated Name:
Business Name/Trade Name:
Business Mailing Address:
City:
Business Website:
Please detail your business aspirations, project, and scope. If your business is operational, please describe your business and include the number of full-time staff and part-time staff:
SECTION 8 – BACKGROUND INFORMATION (PLEASE COMPLETE ALL FIELDS)
Please describe your relevant work experience or training (resume must be attached).
If you are interested in entrepreneurship training (such as the Praxis School of Entrepreneurship, bookkeeping, workshops, etc.), please include details about the training program, including cost and duration.
If you are interested in training related to your business industry, please include details about the training program, including cost and duration:
June 2019 Pride. Perseverance. Possibilities.
Do you have a strong credit history (please explain)?
Do you project costs and potential financing align with the scope of your project? Do you have personal equity/cash to contribute to the project?
Financing
Client equity/cash:
Bank:
CCDF:
SMEDCO:
Total Financing:
Project Costs (should equal the amount of financing needed)
Land or buildings:
Equipment:
Initial inventory:
Total Costs:
Have you completed market research for your business idea? What are your findings? Can you identify an area of competitive advantage?
Have you developed a draft business plan or approached external agencies for professional business plan development? If yes, detail what stage of business planning you are in.
Did you work with an agency to start/complete your business plan?
What representative did you worked with?
*If you have completed a business plan, please attach it to your application
June 2019 Pride. Perseverance. Possibilities.
SECTION 9 – START-UP INFORMATION (PLEASE COMPLETE ALL FIELDS IF YOU ARE STARTING OR EXPANDING A BUSINESS)
SECTION 9 – PERSONAL FINANCIAL STATEMENT - TO BE COMPLETED BY EACH MÉTIS BUSINESS OWNER
June 2019 Pride. Perseverance. Possibilities.
Financial Information as of , Name:
ASSETS (List and Describe) LIABILITIES (List and Describe)
Total Chequing: Bank Loans:
Total Savings: Mortgages:
Vehicles: Monthly Rent:
Stocks/Bonds: Credit Card Debt:
Real Estate Owned: Loans/Obligations:
Retirement Accounts:
Total Assets: Total Liabilities:
Net Worth:
Have you ever had an asset repossessed? No Yes
Have you ever declared bankruptcy? No Yes, When:
Do you owe any taxes prior to the current year? No Yes
Are you currently involved in any legal matters? No Yes
MONTHLY INCOME EXPENSES
Gross Monthly Salary Bank Loans
Spouse Monthly Salary Mortgages/Rent
Monthly Rental Income Insurance
Canada Child Benefit Credit Cards
Transportation
Utilities
Total Income Total Expenses
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June 2019 Pride. Perseverance. Possibilities.
CLIENT CONSENT AND RELEASE FORM
Source of Financial Support:
ISET – Employment Insurance Part I and/or II
ISET – Consolidated Revenue Fund
Employment Insurance Part I
Preamble:
For clients participating in any Indigenous Skills and Employment Training (ISET) Program activities, personal information will be collected and shared by Gabriel Dumont Institute Training and Employment Inc. with Canada to verify clients’ eligibility to ISET Program activities and determining the most appropriate source of financial support for clients and, for subsequent evaluation and accountability purposes.
As a condition of participating in an ISET Program activity, you are required to give your written consent to the collection, use and release of your personal information by the above noted ISET agreement holder. You are also required to give written consent to the Government of Canada for to the collection, use and release of your personal information.
Privacy Notice: What you need to know about your personal information being collected by GDI Training & Employment:
The personal information you provide is collected and administered under the authority of the Department of Human Resources and Skills Development Act and will serve to administer and enforce ISET Program activities. The Social Insurance Number (SIN) is also collected under the authority of the Department of Human Resources and Skills Development Act and in accordance with the Treasury Board Secretariat Directive on the SIN which lists Aboriginal Programs (Human Resources and Skills Development Canada) as an authorized user of the SIN in Appendix A.
SPF – Apprenticeship
WD – Entrepreneurship
Client Information:
Middle Initial:
Province: Postal Code:
First Name:
Last Name:
Address:
City:
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June 2019 Pride. Perseverance. Possibilities.
What you need to know about your personal information being shared with Canada or other third parties:
The personal information provided by the above noted ISET agreement holder for any ISET Program activities to Canada, is administered in accordance with the Part 4 of the Department of Human Resources and Skills Development Act and the Privacy Act.
The information provided may be used and/or released by Canada for policy analysis, research and/or evaluation purposes such as to obtain views and opinions on the ISETS through participants surveys as well as to conduct accountability activities such as monitoring and evaluation and, ensure data quality. In order to conduct these activities, various sources of information under the custody and control of Employment and Social Development Canada (ESDC) may be linked. However, these additional uses and/or releases of personal information will never result in an administrative decision being made about clients.
The SIN will be used for monitoring, assessing, and evaluating the effectiveness of assistance funded by Canada. The SIN will also be used to ensure an individual’s exact identification so that contributory earnings can be correctly posted allowing for benefits and entitlement to be accurately calculated.
∞ For EI Clients:
For EI clients receiving assistance under ISET, the above noted ISET agreement holder, or its sub-agreement holder, will provide to Canada personal information under its control about each EI client receiving assistance to assist Canada in:
• Verifying clients’ eligibility for, or entitlement to, insurance benefits under Part I of theEmployment Insurance Act.
• Ensuring that EI clients who are active EI claimants continue to receive the insurance benefitsto which they are entitled while participating in the program, as per section 25 of theEmployment Insurance Act.
The above noted ISET agreement holder has been designated as a referral authority, as per Schedule B of the ISET contribution agreement, to better coordinate the provision of assistance by the Recipient to participants in its programs who are active EI claimants with the payment of insurance benefits.
How to access your personal information from ESDC:
You have the right to the protection of, and access to, your personal information. It will be retained in Personal Information Bank HRSDC PPU 101. Instructions for obtaining this information are outlined in the government publication entitled Info Source, which is available at the following web address: http://www.infosource.gc.ca. For more information, please consult the Info Source website or contact ESDC’s Access to Information and Privacy Coordinator at: (819) 654-6972.
How to access your personal information from the ISET agreement holder:
Your personal information is retained at your local service delivery office, with backup copies retained at the Gabriel Dumont Institute Training & Employment central administrative office in Saskatoon. Your personal information is also stored securely in the ARMS Client Management System. You may submit a written “Request for Personal Information” to your Employment Counsellor, or to any service delivery office. Requests for Personal Information will be responded to within thirty days after the request is received.
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Pride. Perseverance. Possibilities.
Consent and Release:
I, undersigned, confirm that I have read and understood the above privacy notice, or that it has been explained to me, and authorize any person, corporation, organization, government or government agency to release any of my personal, financial or other information or documents requested by or on behalf of Gabriel Dumont Institute. I nominate Gabriel Dumont Institute as my agent to receive any such information or documents for any purpose related to their programs or financial assistance available to me.
I consent to and authorize Gabriel Dumont Institute or its designate(s) to the collection, exchange and release of my personal information to any government or government agency or, to any educations or financial institution, any information or documents pertaining to me including any personal or financial information for the purpose of administering financial assistance.
I understand why I’ve been asked to disclose my personal information and am aware of the risks or benefits of consenting, or refusing to consent, to the disclosure of my information. I understand that I may revoke this consent in writing at any time.
Client Name (Printed):
Employment Counsellor
Client Signature
June 2019 Pride. Perseverance. Possibilities.
AUTHORIZE A REPRESENTATIVE
Client Name (Printed)
Client Signature Date
I, undersigned, authorize Gabriel Dumont Institute to release my personal information including:
Status and details of my application
Details on my funding amounts
Payment information
Counseling Notes, Assessment and Action Plan
All personal information contained in my client file
to my chosen representative:
Name:
Relation:
Phone:
Email:
Pride. Perseverance. Possibilities.
DIRECT DEPOSIT ENROLLMENT
Name:
Address:
City/Town: Postal Code:
(or Teller Stamp Here) If Direct Deposit Printout from your Online Banking is not available,
a VOID Cheque or Teller StampMust be Attached
If a VOID Cheque or Direct Deposit printout from your Online Banking is not available, the following MUST be filled out, and stamped, by your financial institution:
( 3 Digits )
( 5 Digits )
Institution Number:
Branch Number:
Account Number:
I, hereby authorize Gabriel Dumont Institute Training & Employment Inc. (GDI) to make deposits into my account.
GDITE Client ID:
June 2019 Pride. Perseverance. Possibilities.
DAY CARE VERIFICATION FORM
Client Name:
Day Care Provider:
Provider SIN or Business Number:
Day Care Address:
Day Care Telephone:
Name of Child Age Birth Date (Day/Month/Year)
First day that day care will be provided:
Total cost of day care services (fill out one): Daily:
Monthly:
Subsidized (Parent Portion):
Provider Signature Date
Client Signature Date
The client will notify GDI Training and Employment of any changes to the Day Care provider and will provide receipts for payments made for day care prior to reimbursement.
Pride. Perseverance. Possibilities.
EMPLOYMENT INSURANCE CLAIM INQUIRY
Initial Inquiry
2 Weeks before Training
Mid-Intervention
End of Training/Expiry of Benefits
Employment Counselor: Date:
Claimant Information
Client Name: S.I.N.:
Training Start Date: Training End Date:
GDITE Authorized User Only
Intervention Status:
Eligibility: CRF Eligibility: EI
No Claim
Ineligible -
Eligible (Reachback) -
Active Claim -
Claim Type:
EI Benefit Rate: Expected End Date:
EI Claim Info:
Benefit Period Commencement:
Weeks Eligible: Weeks Paid:
Last Week Processed:
Expected End Date of Part 1:
Renewal Week:
Disqualification or Disentitlement
Comments:
Resubmit in 2 weeks
Completed by: Date: Authorized User
*Special Claims (Maternity, Parental, Sickness, Fishing, Compassionate) are not eligible and must be converted to Regular Benefits.*BPNE (Benefit Period Not Established) indicates that client did not have enough hours to qualify.*MPS Claim (Manual Pay System) indicates Service Canada must be contacted to determine eligibility – forward to Chelsie or Angie
**FOR COUNSELLOR USE ONLY**
January 2020 Pride. Perseverance. Possibilities.
REQUEST FOR AUTHORIZATION TO QUIT EMPLOYMENT
EI Eligibility CRF Eligibility
GDITE Client ID:
Present Employment:
Planned Intervention:
Counsellor Comments and Recommendations:
CTQ Criteria:
CTQ Criteria:
Employment Counsellor: ESM:_____
OFFICIAL USE ONLY
Client is authorized to quit employment effective:
Authorization to Quit is denied. Comments:
________________________________________ _________________________ Authorizing Signature Date
Program Requested:
Anticipated Program Start Date:
Anticipated Program End Date:
Client will be relocating from to
Employer Name:
Hourly Wage:
Hours Worked/Week:
Client is authorized to maintain employment during training intervention.
Employer Name:
Hourly Wage:
Hours Worked/Week: