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* 1. Your Contact Information

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* 2. Are you a Canadian citizen eligible to Work in Canada?

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* 3. Date of Birth

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* 4. Are you currently employed?

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* 5. Are you currently on EI benefits or have received EI in the past 5 years?

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* 6. Do you have a valid driver's license?

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* 7. Education & Training Information

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* 8. Do you self-identify as a "person with a disability"

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* 9. Do you require assistance to prepare for, secure, maintain and grow employment and self-employment opportunities?

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* 10. What other factors are affecting your current employability?

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