Client (Recipient of Services)

Main Contact Person

Title

Address

City and Province/Territory

Postal Code

Phone (with area code)

Fax (optional)

Cell (optional)

E-mail

(I don't have an e-mail address.)

Website Address (optional)

1. Have you received CESO assistance in the past?
Yes   No

2. How did the client learn about CESO?
Personal contact
Business contact
Conference/Tradeshow
Promotional Material
CESO Website
NationTalk
Internet (Other Sites)
Radio
Magazine/Newspaper
Yellow Pages
Other (describe):

3. Indicate one of the following that pertains to the Client (Recipient of Services):
First Nation
Inuit
Métis
Non-Aboriginal
Other:
If applicable, please name affiliation:

4. a) Please describe your organization (select ONE that best applies):
Governance/Administration
Community Program Services
Financial Institution
Friendship Centre
Training or Educational Institution
Goverment Agency
Women's Association
Other – describe:
Business (if selected, please go to 4b)

    b) For businesses, describe ownership (check all that apply):
First Nation
Métis
Inuit
Individual
Partnership
Community/Cooperative
On-Reserve
Off-Reserve
Year Established:
Type of Business:

5. What do you want the Volunteer Adviser (VA) to assist you with? If your request is for a workshop, please describe your needs or identify the title of the workshop.

6. What prompted the request for assistance? Please be specific.

7. Please describe the expected results from the assistance provided by the VA.

8. Please identify the specific skills and experience required of the VA.

9. How many people will be involved in the training or participating in the workshop?

10. What is your preferred start date?
Estimated completion date?

11. Has the initiative received approval from your local government, Board of Directors, or other?
Yes  No  Please explain:

12. Are funds available for this initiative/venture?
Yes  No  Please explain:

I confirm that the information contained in this Request for Services form is accurate and represents the requirements of the Client.

 I understand that the $150 Application Fee, payable to CESO, is non-refundable unless CESO is unable to find a suitable VA to provide the assistance requested above.

I understand that a contract will follow providing an estimate of costs based on the nature of assignment and the VA(s) selected.

Completed by:

Name
Title

Date