Co-operative Education/Internship Program

APPLICATION FOR EMPLOYMENT

• Attach your résumé
• Use printed uppercase block letters
• Sign this form

Surname:   Given name:  

Middle initials:  

PRI: (see instructions)  / / 

Address:  

City:   Province:  

Postal code:  / / / / / /

You are entitled to work in Canada by reason of (check one only):

  Canadian citizenship   Permanent resident status   Work permit

EMPLOYMENT EQUITY (see instructions)

1. Male   Female  
2. Aboriginal person  / /
3. Person in a visible minority group  / /
4. Person with a disability  / /

DECLARATION

All the information submitted in this application is true, complete and may be verified. Any false information may result in the rejection of this application.

Signature:   Date:  

PRIVACY ACT

Necessary measures have been taken to protect the confidentiality of the personal information you provide.

• The information you provide is collected under the authority of the Public Service Employment Act. We will use this information to determine your eligibility for employment. Some government departments may also use it for related statistical studies. Be assured that any statistical uses will in no way identify you personally.
• Your personal information will be held in the Departmental Employee Standard Bank (Staffing). It is protected under the Privacy Act.

According to the Privacy Act, you have rights with respect to the information you submit.

You may, upon request:

• be given access to your file;
• have incorrect information corrected or have a notation attached.

For more information about your rights, see Info Source, a Government of Canada publication available in major libraries, at government information offices and from constituency offices of federal Members of Parliament.

PRI

If you have previous experience with a federal department and have been assigned a Personal Record Identifier (PRI) number, please record it in the space provided. Your PRI number was indicated on your pay-cheque stubs.

EMPLOYMENT EQUITY

The Public Service of Canada is committed to the principle of merit and to ensuring equitable participation of women, Aboriginal peoples, persons with disabilities, and members of visible minority groups. Information in this section is collected under the authority of the Employment Equity Act, Section 9, and its confidentiality is protected under the Privacy Act. Your response to these questions is voluntary, and may be used both for statistical purposes and in considering you for programs that help in creating a more representative Public Service. For persons with disabilities, it will also ensure the provision of appropriate accommodations.

Note: A person may be a member of more than one designated employment equity group.

1. Gender This information will help us to ensure equality of access for both men and women to all positions in the Federal Public Service.
2. An Aboriginal person is a North American Indian or a member of a First Nation, a Metis or an Inuit. North American Indians or members of a First Nation include "Status," "Treaty" or "Registered" Indians, as well as "Non-Status" and "Non-Registered" Indians.
   • 01 Inuit
   • 02 Métis
   • 03 North-American Indian/First Nation Indian
3. A person in a visible minority group in Canada is someone other than
   an Aboriginal person as defined above, who is non-white in colour/race,
   regardless of his/her place of birth.
   • 41 Black
   • 42 Non-White Latin American (including indigenous persons from Central and South America, etc.)
   • 45 Chinese
   • 47 Japanese
   • 48 Korean
   • 51 Filipino
   • 56 South Asian/East Indian (including Indian from India; Bangladeshi; Pakistani; East Indian from Guyana; Trinidad; East Africa; etc.)
   • 57 Non-White West Asian, North African or Arab (including Egyptian; Libyan; Lebanese; Iranian; etc.)
   • 58 Southeast Asian (including Burmese; Cambodian; Laotian; Thai; Vietnamese; etc.)
   • 44 Person of Mixed Origin (with one parent in one of the visible minority groups listed above)
   • 59 Other Visible Minority Groups
4. A person with a disability (i) has a long-term or recurring condition or health problem that may limit the kind of amount of work he/she can do in the workplace; or (ii) feels that he/she may be perceived as limited in the kind or amount of work which he/she can do because of physical, mental, sensory, psychiatric or learning impairment.
   • 11 Co-ordination of dexterity (difficulty using hands or arms, for example, when grasping or handling a stapler or using a keyboard)
   • 12 Mobility (difficulty moving around, for example, from one office to another or up and down stairs)
   • 13 Speech impairment (unable to speak or difficulty speaking and being understood)
   • 16 Blindness or visual impairment (unable to see or difficulty seeing)
   • 19 Deafness or hard of hearing (unable to hear or difficulty hearing)
   • 23 Other disability (including learning disabilities, developmental disabilities, all other types of disabilities)