Self Employ PEI Application Section A - Personal InformationUnique IDSocial Insurance NumberFile NumberSurnameGiven NameMiddle NameAddressCommunity / CityProvincePostal CodePhoneOther PhoneEmail Date of Birth Month Day Year GenderMaleFemaleDo you have a permanent disability?YesNoNature of DisabilityDeaf, hard of hearingBlind, visually impairedPhysical disabilityLearning disabilityOtherDoes this disability restrict your ability to participate in studies at the post-secondary level or in the labour force?YesNoIf you are applying for financial consideration related to your disability, please complete and submit the Permanent Disability Medical Form or, for a learning disability, submit a written diagnossis from a psychologist.Are you a Canadian Citizen?YesNoAre you a Permanent Resident?YesNoWhat is your preferred language of service?EnglishFrenchWhat is your preferred language of correspondence?YesNoAre you a member of an Aboriginal Group?YesNoPlease specify if you consider yourself to be a member of one fo the following priority groups.ImmigrantYouthWomenVisible MinorityPerson with DisabilitiesOlder WorkerSection B - EligibilityHave you applied for or are you currently in receipt of Employment Insurance?YesNoHave you had an Employment Insurance claim that ended in the past 60 months?YesNoHas your business name already been registered?YesNoAre you currently active in the business or any other business venture?YesNoHave you received any previous funding under programs administered by the Government of Prince Edward Island or Human Resources and Skills Development Canada?YesNoSection C - Client Goal and ContributionWhat are your contributions towards establishing your own business and how will this contribution be used? This can include in-kind contributions or cash contributions.Section D - Amounts Owing in Default to the Government of PEIDo you, the applicant, owe any amounts that are in default to the Government of PEI?YesNoAmounts in Default OwingNature of the Amount Owing (taxes, etc.)Government Department or Agency Owed Do you currently have an order or judgement for maintenance, alimony or family financial support against you?YesNoDo you currently have an obligation under an agreement for the payment of maintenance or family financial support in respect of which a garnishee summons has been served on the Department of Justice under the Family Orders and Agreements Enforcement Assistance Act?YesNoIf you have a garnishee summons, it is important to contact the Maintenance Enforcement Program at the Office of the Attorney general to determine whether (and how much) of your Self Employ PEI financial assistance may be garnished. In some instances it may be possible for you to negotiate suspension or reduction of the garnishment during Self Employ PEI participation. This situation should be resolved so you know whether you can participate in Self Employ PEI before the final approval of your Self Employ PEI application.Section E - Supporting DocumentationYour application will not be assessed until the following documents are attached to support your request. Please select each item you wish to upload and attach now to this application form. Those unchecked must be provided at a later date.Return-To-Work Action PlanBusiness PlanResumeEnvironmental impact assessment (if necessary)Evidence of personal investmentExchange of information form (if required)Hold down your CTRL or command key to select more than one value.Upload Return-To-Work Action PlanUpload Business PlanUpload ResumeUpload Environmental Impact AssessmentUpload Evidence of Personal InvestmentUpload Exchange of Information FormSection F - Declaration I declare: (a) I have read and understand the information provided in this application package; (b) The information I have provided to the Department of Workforce and Advanced Learning & SkillsPEI in this application and supporting documentation is true, accurate and complete in every respect; (c) If the information described above is false or misleading, I may be required to repay some or all of the financial assistance that may be approved by the Department of Workforce and Advanced Learning & SkillsPEI; (d) The information provided, with respect to amounts owing in default to the Government of PEI, is true and accurate. I recognize that amounts payable to me under any future agreement may be deducted from, or set-off against, any such amounts owing to the Government of PEI. I agree: (a) The information I have provided in this application can be subject to a proof of evidence request at any time during this agreement. I authorize: (a) the Minister of Workforce and Advanced Learning to disclose all information contained in this application concerning an amount in default owing to the Government of PEI listed in Section “E” for the purpose of verifying the amount and status of debt, and (b) the Government of PEI to disclose to the Minister of Workforce and Advanced Learning all particulars and information relevant to the debt solely for the purpose of the administration of my application in connection with my declaration as to amounts owing to the provincial government that are in default.