Referral Information

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* Employee Name:

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* Type:

Work Status

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* Work Status

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* Work Status Dates

*Correct collective agreement, union and Employer ID information is required to meet privacy requirements. If you need help with this information please contact HEABC directly by email at edmp@heabc.bc.ca or by phone at (604)742-5517
Union

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* Collective Agreement:

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* Union (Enter Union name)

Employer

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* Employer ID #:  [4 digit]

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* Employer Name:

Demographic & Contact

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* Date of Birth:  (mm/dd/yyyy)

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* Employee Phone:

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* Personal Email Address (if available):

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* Employee Street Address:

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* Employee City:

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* Employee Postal Code:

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* Employee Type:

Job & Department

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* Job Title:

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* Date of Hire (optional):  (mm/dd/yyyy)

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* Work Site Name (if applicable):

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* Department (if applicable):

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* Manager/Supervisor Name:

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* Manager/Supervisor Phone:

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* Manager/Supervisor Email:

Employer’s Main Contact Person (if different than the Manager/Supervisor listed above)

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* Name:

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* Phone:

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* Email (a copy of this referral will be emailed):

Additional Information
If you would like a copy of this referral form, please note a copy will be sent to the Employer email entered above. 

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* If there is any additional information please indicate below:

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* Would you like to attach supporting documents?

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