Email Address: ... Ext: 2043 & 2041 Email:
| Web: www.successbiis.ca .... 2) Identify why yo
YOUTH BUSINESS INNOVATIVE IDEA STARTUPS
INTAKE APPLICATION FORM
28 West Pender St. Vancouver, BC, V6B 1R6 | Phone: 604‐408‐7274 Ext: 2043 & 2041 Email:
[email protected] | Web: www.successbiis.ca
Agreement Number: _____________________ (Office use only) Participant Identification Participant Name: ______________
/__________________/_________________________
First Name
Date of Birth:
Middle Name
Last Name
_______/________/_______ Place of Birth: _____________________________ Year
/ Month
/ Day
Country
City
Participant Identification Source: Driver’s License Birth Certificate BCID Passport PR Card Status Card or Other (please specify): NOTE: Indicate only the type of identification that was used to confirm the participant identity.
Phone Numbers:
Personal (______) ________________ Alternate (______) ____________________
Email Address:
____________________________________________________________________
Residential Address: ___________________________________________________________________ Road Address ___________________________________________________________________________ City / Town
Postal Code
If your Residential Address is different than your Mailing Address then complete the following:
Mailing Address:
____________________________________________________________________ Mailing Address ___________________________________________________________________________ City / Town Postal Code
1.
Gender:
Male Female
Other
2.
Do you consider yourself a Person with a Disability? Yes No Prefer not to answer
3. Do you consider yourself as a visible minority? (The Employment Equity Act defines visible minorities as "persons, other than Aboriginal peoples, who are non-Caucasian in race or non-white in colour". The visible minority population consists mainly of the following groups: Chinese, South Asian, Black, Arab, West Asian, Filipino, Southeast Asian, Latin American, Japanese and Korean)
Yes No Prefer not to answer
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YOUTH BUSINESS INNOVATIVE IDEA STARTUPS
INTAKE APPLICATION FORM
28 West Pender St. Vancouver, BC, V6B 1R6 | Phone: 604‐408‐7274 Ext: 2043 & 2041 Email:
[email protected] | Web: www.successbiis.ca
4.
Do you identify yourself as an Aboriginal Person (First Nations, Métis or Inuit)? Yes No Prefer not to answer *If yes, answer 4a & 4b 4a. If you identify as an Aboriginal Person, are you: First Nations Métis Inuit Prefer not to answer 4b. where do you live? On Reserve Off Reserve Prefer not to answer
5.
A) Did you immigrate to Canada? Yes No If yes, what year did you immigrate? _______ Immigration category___________________________ B) Citizenship – Are you a: Canadian Citizen Permanent Resident Protected Person entitled to work in Canada
6.
A) Are you an apprentice? Yes No
Prefer not to answer
If yes, which trade? ____________________ Company name _______________________________
B) If yes, are you registered with the Industry Training Authority? Yes No Prefer not to answer 7.
What is your highest level of education achieved? Less than high school High School Some Post-Secondary Trades Certificate or diploma Diploma University Degree 7A) Name of the last school you attended ________________________________________________ 7B) Where is the school? ______________________ Country
8.
________________________________ City
Which best describes your pre-intervention employment status? Employed – a person having a job or business Employed in a trade occupation Employed as an apprentice Self Employed – Self-employed persons are working owners of an incorporated or unincorporated business, farm or professional practice, with or without paid help. Unemployed – without work, are available for work, and are actively seeking work. In school or training In Trades Foundation Training Not in the labour force – persons who, during the reference week, were unwilling or unable to offer or supply labour services under conditions existing in their labour markets (this includes persons who were full-time students currently attending school). If you answered ‘Employed’ or ‘Self Employed’, please complete questions 9, 10, 11, and 12. Otherwise continue to question 13.
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YOUTH BUSINESS INNOVATIVE IDEA STARTUPS
INTAKE APPLICATION FORM
28 West Pender St. Vancouver, BC, V6B 1R6 | Phone: 604‐408‐7274 Ext: 2043 & 2041 Email:
[email protected] | Web: www.successbiis.ca
9.
If Employed or Self Employed what are your: Average Weekly Hours: Average Hourly Wage: $
10. What is your employment type? Seasonal Employment – a job where an employee is working in an industry where employment levels rise or fall with the seasons (e.g., agriculture, fishing, logging and tourism) Temporary Employment – a job that has a predetermined end date or will end as soon as a specific project is completed. Casual Employment – when an employee's work hours vary substantially from one week to the next, if the employee is called to work by the employer when the need arises and not on a pre-arranged schedule, or if the employee does not usually get paid for time not worked and there is no indication from the employer about work on a regular basis for a long duration. Permanent Employment – when a job is expected to last as long as the employee wants the job and as long as business conditions permit. None of the above 11. A) What is your occupation? Provide 4 digit NOC code: or describe the occupation for code entry later: http://www.cic.gc.ca/english/immigrate/skilled/noc.asp#find Occupation Level A: __________________________________________________________ Occupation Level B: __________________________________________________________ Occupation Level C: __________________________________________________________ Occupation Level D: __________________________________________________________ B) North American Industry Classification System (NAICS) Code: __________________ 12. How long have you been employed/self-employed in this job? Years plus
Months
13. Have you received or are you receiving Employment Insurance (EI) benefits in Canada? Currently In the last month In the last 3 months In the last 36 months (3 years) In the last 60 months (5 years) If yes to above, were these maternal/paternal benefits? Yes No None of the above (not eligible for EI) 14. Are you currently receiving Income Assistance? Yes No 15. What do you expect will be the most important result of receiving this service? ____________________________________________________________________________ ____________________________________________________________________________
Page 3 of 5
YOUTH BUSINESS INNOVATIVE IDEA STARTUPS
INTAKE APPLICATION FORM
28 West Pender St. Vancouver, BC, V6B 1R6 | Phone: 604‐408‐7274 Ext: 2043 & 2041 Email:
[email protected] | Web: www.successbiis.ca
1. Business Proposal Please provide all relevant information to the points listed below: 1) Briefly describe the idea for your business and why you have chosen it.
2) Identify why you think this is a good business idea.
3) What sort of research have you done?
4) Whom have you talked to about it and what was their reaction?
5) What personal and entrepreneurial qualities you possess?
6) When is your tentative date of business startup?
Page 4 of 5
YOUTH BUSINESS INNOVATIVE IDEA STARTUPS
INTAKE APPLICATION FORM
28 West Pender St. Vancouver, BC, V6B 1R6 | Phone: 604‐408‐7274 Ext: 2043 & 2041 Email:
[email protected] | Web: www.successbiis.ca
2. Financial Information 1) What is the estimated startup cost? e.g. Business licensing, equipment, inventory etc.
2) Estimated monthly working capital for 6 months? e.g. Salary/labour cost, rent/lease etc.
3) What is your source of fund? e.g. personal savings, business loan, angle investment, family/friends source.
4) Available fund for investment
3.
Privacy Agreement Youth Entrepreneurship Program Commitment to Privacy Statement
Youth‐BIIS is committed to protecting personal information by employing responsible information handling practices and respecting privacy information laws. We collect, use and disclose personal information in order to better meet your service needs, to ensure the safety of our participants, for statistical purposes, to satisfy government and regulatory obligations, and to inform you about S.U.C.C.E.S.S. programs and services.
I would like to hear from Youth‐BIIS periodically about other S.U.C.C.E.S.S. programs, services, workshops, training, networking or opportunities that may be of interest.
By signing below, I am indicating that I understand that the Youth‐BIIS program will collect, use and disclose my personal information contained within this Application for the Youth‐BIIS program for the above‐noted purposes only, and I consent to the release of my personal information by the Youth‐BIIS program to S.U.C.C.E.S.S. and the Government of BC which funds the Youth‐BIIS program.
Signature of the Applicant: _____________________________
Date: _____________________
Printed Name: _______________________________________
Where did you hear about Youth BiiS Program? Youth BiiS Website SUCCESS Website Social media __________ Magazine/ Newspaper_____________ Family/Friend Referral ______________ Google search Youth BiiS Flyer/Poster location______________ Library / Library website ___________________ other sources_______________________________________
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