Employment and
Social Development Canada
Emploi et
Développement social Canada
APPLICATION FOR A WORK-SHARING AGREEMENT
(TO BE COMPLETED BY SERVICE CANADA OFFICIAL)
OFFICIAL USE
1. TYPE OF APPLICATION
2. PREVIOUS AGREEMENT NUMBER
FILE NUMBER
3. END DATE OF PREVIOUS AGREEMENT
DEPARTMENT
INITIAL
SUBSEQUENT
(TO BE COMPLETED BY THE EMPLOYER)
PART 1 - EMPLOYER INFORMATION
4. NAME OF EMPLOYER
5. DATE BUSINESS ESTABLISHED IN CANADA
6. LEGAL NAME OF EMPLOYER
7. STREET ADDRESS
8. CITY/TOWN
9. PROVINCE/TERRITORY
YYYY - MM - DD
10. POSTAL CODE
11. MAILING ADDRESS (IF DIFFERENT FROM EMPLOYER ADDRESS)
12. AREA CODE/ TELEPHONE NUMBER
13. AREA CODE/FAX NUMBER
14. E-MAIL ADDRESS
15. WEB SITE (IF APPLICABLE)
16. CANADA REVENUE AGENCY
TAXATION NUMBER
17. NAME AND TITLE OF AUTHORIZED EMPLOYER
REPRESENTATIVE
18. AREA CODE/TELEPHONE NUMBER
(IF DIFFERENT FROM ABOVE)
19. TOTAL NUMBER OF EMPLOYEES AT
THIS LOCATION
20. NAME OF UNION OFFICIAL
21. AREA CODE/ TELEPHONE NUMBER
22. NAME OF UNION AND LOCAL NUMBER
23. NAME OF EMPLOYEE REPRESENTATIVE
24. AREA CODE/ TELEPHONE NUMBER
25. NAME OF BOOKKEEPER or ACCOUNTANT
26. AREA CODE/ TELEPHONE NUMBER
27. HAS YOUR COMPANY SUBMITTED ONE OR MORE APPLICATIONS TO ANY OTHER
SERVICE CANADA CENTRES?
Yes
No
IF YES, PLEASE INDICATE THE LOCATION OR LOCATIONS
28. PLEASE ATTACH A DESCRIPTION OF WHAT YOUR BUSINESS DOES AND A BRIEF HISTORY OF THE COMPANY INCLUDING TYPE OF GOODS
PRODUCED/SERVICES PROVIDED AND TYPICAL CLIENTS.
29. PLEASE ATTACH A RECORD OF YOUR SALES OR PRODUCTION AND THE NUMBER OF EMPLOYEES (AT THIS LOCATION) BROKEN DOWN BY
MONTH OVER THE LAST TWENTY-FOUR MONTHS.
30. PLEASE PROVIDE DETAILED INFORMATION ON THE CAUSE AND EXPECTED DURATION OF THE WORK SHORTAGE.
31. IS THE LAYOFF OR WORK SHORTAGE DUE TO A LABOUR DISPUTE IN YOUR ESTABLISHMENT,
OR WITH A CUSTOMER, OR SUPPLIER ESTABLISHMENT?
Yes
No
32. PLEASE ATTACH A COMPLETED RECOVERY PLAN TEMPLATE (ATTACHMENT B) PROVIDING A CLEAR OUTLINE OF ACTIVITIES THAT WILL BE
TAKEN BY YOUR COMPANY DURING THE PERIOD OF THE AGREEMENT TO RETURN EMPLOYEES IN THE WORK-SHARING UNITS TO
NORMAL WORKING HOURS.
33. PLEASE PROVIDE A BRIEF DESCRIPTION OF MEASURES TAKEN BY YOUR COMPANY TO OVERCOME THE DOWNTURN IN BUSINESS BEFORE
APPLYING FOR THE WORK-SHARING PROGRAM.
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PART 2 - WORK-SHARING UNIT INFORMATION
34. AVERAGE WEEKLY EARNINGS PER
WORK-SHARING UNIT
(TO BE COMPLETED BY THE EMPLOYER)
35. THE SHORTAGE OF WORK IS EXPECTED
TO BE :
TEMPORARY
36. IF THE LAYOFF IS CONSIDERED TO BE
TEMPORARY, WHEN DO YOU ANTICIPATE TO
RETURN ALL EMPLOYEES TO NORMAL
EMPLOYMENT?
NUMBER OF WEEKS
YYYY - MM - DD
PERMANENT
37. NUMBER OF EMPLOYEES TO BE LAID
OFF TEMPORARILY SHOULD WORKSHARING NOT BE APPROVED
38. NUMBER OF WEEKS OF TEMPORARY LAYOFF
39. NUMBER OF EMPLOYEES TO BE PLACED ON
THE WORK-SHARING PROGRAM (INCLUDING
ANY EMPLOYEES WHO WERE RECENTLY
LAID-OFF)
40. ARE THERE OTHER COMPANY EMPLOYEES
41. WILL ANY EMPLOYEE
WHO WILL NOT BE PLACED ON WORK-SHARING,
SHAREHOLDERS BE PLACED ON
BUT WHO PERFORM THE SAME JOB DUTIES AS
WORK-SHARING?
THOSE ON THE PROGRAM?
Yes
42. ARE THERE ANY PLANNED SHUT DOWNS?
Yes
No
No
Yes
YYYY - MM - DD
IF YES, WHEN?
No
YYYY - MM - DD
TO
43. APPROXIMATELY HOW MANY HOURS/DAYS/SHIFTS OF WORK PER WEEK CAN YOU OFFER EACH EMPLOYEE WHILE THEY ARE ON THE
WORK-SHARING PROGRAM?
PART 3 - COSTS
(TO BE COMPLETED BY THE EMPLOYER)
44. NUMBER OF WEEKS OF WORK-SHARING
REQUESTED
45. PERCENT REDUCTION OF WORK HOURS
46. REQUESTED START DATE OF
WORK-SHARING AGREEMENT (MUST BE A
SUNDAY)
SUBECT TO THE TERMS OF THE WORK-SHARING AGREEMENT, ALL INFORMATION CONTAINED IN THIS APPLICATION PROVIDED BY THE
EMPLOYER, THE UNION OR UNIONS OR EMPLOYEE RESPRESENTATIVES WILL BE TREATED AS CONFIDENTIAL IN ACCORDANCE WITH
APPLICABLE LEGISLATION AND USED SOLELY FOR THE PURPOSE OF DETERMINING ELIGIBILITY UNDER THE WORK-SHARING INITIATIVE OF
THE WORK-SHARING PROJECT DESCRIBED IN THIS APPLICATION, AND IN SUPPORT OF RESEARCH AND STATISTICAL GATHERING ACTIVITIES.
THE EMPLOYER AGREES TO PROVIDE SUCH DOCUMENTATION AS MAY BE REQUIRED BY THE CANADA EMPLOYMENT INSURANCE
COMMISSION (COMMISSION), INCLUDING COPIES OF PAYROLL RECORDS, FOR THE PURPOSE OF VERIFYING THE INFORMATION PROVIDED
ON THIS FORM.
THE EMPLOYER AND THE UNIONS OR EMPLOYEE REPRESENTATIVES HEREBY MAKE APPLICATION FOR APPROVAL BY THE COMMISSION
OF THEIR WORK-SHARING PROJECT IN ACCORDANCE WITH SECTION 24 OF THE EMPLOYMENT INSURANCE ACT AND SECTIONS 42 - 49 OF
THE EMPLOYMENT INSURANCE REGULATIONS BUT AGREE THAT THE PREPARATION AND FILING OF THIS APPLICATION DOES NOT CREATE
ANY OBLIGATION ON THE PART OF THE EMPLOYER, THE UNIONS, THE EMPLOYEE REPRESENTATIVES OR THE CANADA EMPLOYMENT
INSURANCE COMMISSION.
IT IS UNDERSTOOD THAT DELIBERATELY GIVING FALSE OR MISLEADING INFORMATION FOR THE PURPOSE OF ENTERING INTO A WORKSHARING AGREEMENT SHALL BE SUBJECT TO THE PENALTIES AS PROVIDED UNDER THE EMPLOYMENT INSURANCE ACT.
SIGNATURE
DATE
SIGNATURE
DATE
SIGNATURE
DATE
YYYY - MM - DD
FOR THE EMPLOYER
YYYY - MM - DD
FOR THE UNION
YYYY - MM - DD
FOR THE EMPLOYEES
AN ATTACHMENT A (EMP 5101) LISTING ALL EMPLOYEES IN THE WORK-SHARING UNIT(S) MUST BE SUBMITTED ALONG WITH THIS
APPLICATION FORM. ALL NON-UNION EMPLOYEES AS WELL AS THE EMPLOYEE/UNION REPRESENTATIVE MUST SIGN THE ATTACHMENT A.
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