ESDC EMP**** (****-**-***) E Page * of *

**. IF YOU ARE NOT CURRENTLY A STUDENT, HOW LONG HAVE YOU BEEN OUT OF THE EDUCATION SYSTEM? PROJECT NUMBER

EMPLOYER DECLARATION

(Please complete this section, then pass this form to the employee.) 1. LEGAL NAME (AS PER THE CSJ AGREEMENT)

2. ADDRESS 3. POSTAL CODE 4. TELEPHONE NUMBER

JOB INFORMATION

5. START DATE (yyyy-mm-dd) 6. END DATE (yyyy-mm-dd) 7. JOB TITLE 8. HOURS PER WEEK 9. HOURLY RATE I hereby declare that no preference was given to the selection of an employee who is a member of the immediate family of the recipient, an officer, or director of the recipient.

(Employer means the individual or organization receiving funding from Employment and Social Development Canada (ESDC) through Service Canada to employ the person described as "employee" below. The immediate family means father, mother, step-father, step-mother, foster parent, brother, sister, spouse or common-law partner, child (including child of common-law partner), step-child, ward, father-in-law, mother-in-law, or any relative permanently residing with the recipient, an officer, or director of the recipient.) I hereby declare that I have read the health and safety brochure entitled "Are You in Danger?" produced by ESDC, and I understand the content. I have ensured that the employee has been given a copy of the health and safety brochure and has been informed of health and safety requirements related to her/ his position. I believe that she/he also fully understands the content and requirements related to health and safety, and I will attest to that fact by signing below. As a recipient of funds from ESDC, I agree to take responsibility in maintaining a safe work environment for employees. ESDC has created awareness around my responsibilities regarding health and safety for youth in the work environment. I have read and agree to the CSJ Articles of Agreement and the “Calculation of Approved Canada Summer Jobs Contribution Amount”. I certify that I am authorized to sign on behalf of the employer. SIGNATURE NAME AND TITLE (PRINT) DATE (yyyy-mm-dd) EMPLOYEE DECLARATION

10. SOCIAL INSURANCE NUMBER 11. FULL NAME 12. TELEPHONE NUMBER 13. BIRTH DATE (yyyy-mm-dd) 14. NAME OF EDUCATIONAL INSTITUTION LAST ATTENDED 15. FIELD OF STUDY 16.

HIGHEST LEVEL OF

EDUCATION COMPLETED

GRADE 8 OR LESS BETWEEN GRADES

9 AND 12

GRADE 12 COMPLETED

(SECONDARY SCHOOL)

SOME NON-UNIVERSITY POST-SECONDARY

EDUCATION (INCLUDING CEGEP)

UNIVERSITY INCOMPLETE

(1 OR MORE YEARS) BACHELOR DEGREE MASTER OR PHD

INCOMPLETE MASTER OR PHD

17. THIS IS MY FIRST WORK EXPERIENCE

20. I INTEND TO RETURN TO SCHOOL FULL-TIME IN THE

UPCOMING ACADEMIC YEAR

18. IN MY OPINION THIS JOB IS RELATED TO MY FIELD

OF STUDY

19. I WAS REGISTERED AS A FULL-TIME STUDENT IN THE PREVIOUS ACADEMIC YEAR

21. MY RESIDENCY STATUS IS

CANADIAN CITIZEN PERMANENT RESIDENT

PERSON IDENTIFIED AS A REFUGEE UNDER

THE IMMIGRATION AND REFUGEE

PROTECTION ACT.

YES NO YES NO YES NO

YES NO

PROTECTED WHEN COMPLETED - B

Emploi et

Développement social Canada

Employment and

Social Development Canada

CANADA SUMMER JOBS

EMPLOYER AND EMPLOYEE DECLARATION

Service Canada requires this document to validate the eligibility of the employee you have recruited. This form must be completed on the first day of work for, and by, each employee hired through Canada Summer Jobs (CSJ) and must be returned to Service Canada within seven days of the employee beginning employment.

LESS THAN 6 MONTHS 6 MONTHS TO 1 YEAR OVER 1 YEAR OVER 5 YEARS ESDC EMP5397 (2020-08-014) E Page 2 of 2

31. WHAT IS THE LANGUAGE THAT YOU FIRST LEARNED AND STILL SPEAK. Employment and

Social Development Canada

Emploi et

Développement social Canada

PROJECT NUMBER

23. EMPLOYEE PERMANENT ADDRESS (Street number, Street name, City, Province) 24. POSTAL CODE 25. a) EMAIL ADDRESS 25. b) CELLULAR NUMBER

SIGNATURE DATE (yyyy-mm-dd)

INFORMATION ON EMPLOYMENT EQUITY (MANDATORY)

30. RECENT IMMIGRANT * (see definition below)

OTHER

27. INDIGENOUS GROUP:

29. PERSON WITH A DISABILITY

28. MEMBER OF A VISIBLE MINORITY

MALE

FEMALE

OTHER

DECLINE TO

ANSWER

REGISTERED

ON-RESERVE

REGISTERED

OFF-RESERVE

NON-STATUS

N/A

METIS

INUIT

DECLINE TO

ANSWER

YES NO DECLINE TO ANSWER

YES NO DECLINE TO ANSWER

YES NO DECLINE TO ANSWER ENGLISH FRENCH

26. GENDER

*Recent immigrant: is a person who has moved from their country of origin (their homeland) to another country to become a citizen of that country and has been in that country for less than 5 years. EMPLOYEE CONSENT TO RELEASE INFORMATION

CANADA SUMMER JOBS

EMPLOYER AND EMPLOYEE DECLARATION

The information collected in this form will be used to determine your eligibility for CSJ and for subsequent analysis, research or evaluation purposes. Completion of this form is mandatory.

ESDC, on behalf of the Government of Canada, is responsible for the evaluation of the Youth Employment and Skills Strategy (YESS) programs in order to ascertain how beneficial these are to YESS participants. In order to conduct the evaluation activities, your Social Insurance Number will be used to link your employment and income information from ESDC and other sources (i.e. Canada Revenue Agency for income level). Accurate information is essential for ESDC to evaluate the program and conduct participant surveys to ensure that the YESS programs meet your needs. ESDC will also use this information for ESDC YESS program file management and reporting of ESDC's YESS program results. The collection and use of your information by ESDC is allowed by the Employment and Social Development Act. The information collected and its retention period are described in the Personal Information Bank ESDC PPU 706. The information is handled according to the Privacy Act which gives you the right to access and correct your personal information. Instructions for obtaining your information are available at the following website address: https://www.tbs-sct.gc.ca/hgw-cgf/oversight-surveillance/atip-aiprp/ai/atipir-dairp-eng.asp. PROTECTED WHEN COMPLETED - B

I hereby declare that I am legally entitled to work in Canada in accordance with relevant provincial or territorial legislation and regulations and meet the eligibility criteria (Canadian citizen, permanent resident or person to whom refugee protection has been conferred under the Immigration and Refugee Protection Act)1, and I am between the ages of 15 and 30 at the start of the employment. 1International participants are not eligible. Recent immigrants are eligible if they are Canadian citizens or permanent residents. I hereby declare that I have read the health and safety brochure entitled "Are You in Danger?" produced by ESDC, and I fully understand its content. My employer has informed me of what I need to know and what I can do to prevent accidents that would endanger my health and safety at work. As a young worker, I have the right to ask questions, receive information, and take part in actions that will help to make my work environment safer for everyone. I also have the right to refuse to do any work that I feel will put my health and safety in danger. As an employee, I agree to take responsibility in maintaining a safe work environment for my co-workers and myself. ESDC has made me aware of my rights and responsibilities regarding health and safety in the work environment.

I, the undersigned, give my consent to release the information contained in this form regarding my participation in CSJ to ESDC. I acknowledge that the information is collected and administered in accordance with the Privacy Act and applicable privacy laws, and that it may be used to determine my eligibility for the YESS program and provided to ESDC for the evaluation and accountability of the YESS program.

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