Please note Incomplete applications will not be accepted. Please ensure the email address on your application is current. Current SECTION A - Personal Information Complete First Name Last Name Address Address City/Town Province - Select -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonAlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Postal Code Preferred Phone Number Type of preferred phone number: - Select -Cell PhoneHome PhoneWork PhoneOther Secondary Phone Number Type of secondary phone number: - None -Cell PhoneHome PhoneWork PhoneOther Personal Email (Do not use the employer email) Job Title Employer Work Site Name HEU Local (if known) Local meeting election date What HEU Local Executive position do you hold? What is your employment status? Full-time Part-time Casual Region North Interior Vancouver Coastal (includes PHSA) Fraser Vancouver Island Do you identify as a member of any of the following equity groups, or as a young worker? (check all that apply) (check all that apply) Indigenous 2SLGBTQIA+ Persons with disabilities Worker of colour 2-Spirit, Women or Non-Binary Young worker (33 years or younger) None Prefer not to say Emergency contact name Emergency contact phone Do you have any medical condition(s) or is there anything else that we should be aware of that could impact your ability to participate in this event? Yes No If yes, please briefly explain. (In some cases, a physician's note may be required). Which workshop are you attending? Additional opportunity - date to be determined
