Families

Employment and Income Assistance Intake Application Appointment Request Form

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Employment and Income Assistance Intake Application Appointment Request Form

This form is not an application form and submitting the form does not guarantee eligibility for Employment and Income Assistance benefits.
You will be contacted by Employment and Income Assistance staff who will answer any questions you have, collect additional information and schedule your intake appointment.
If you want to make changes, such as correct an error, change your information or cancel your application you may do so when the Employment and Income Assistance staff contact you.

Personal Information

Last Name

First Name

Middle Name

Phone Number

Date of Birth (YYYY-MM-DD)

Email Address

Home Address

City/Town

Province

Postal Code

Application Status

Are you applying as a Single Person (one adult no children) Single Parent (one adult with a child or children under 18) Couple without children (two adults) Couple with children (two adults and a child or children under 18)

Previous Enrollment

Have you previously received EIA benefits? Yes No

Provide your case number (if known)

Were you or your spouse/partner enrolled as a Person with a Disability? Yes No

Today's Date