ACCEP-IEHP Employer Registration Form
Fields marked with an asterisk (*) are mandatory.
Name of Organization/Business
*
Address
*
Street Address Line 1
Street Address Line 2
City
Province
Postal Code
Website
Primary Contact Details
*
First Name
Last Name
Job Title
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Extension (If applicable)
Organization/Business Size (Total Number of Employees in your Branch/Location)
*
1 - 10
11 - 50
51 – 500
501 +
Type of Organization/Business
*
Private
Public
Not for Profit
Other, specify
Service Area (Please choose the service area of your organization/business and check all that applies)
*
Clinical Care Providers - Hospital
Clinical Care Providers - Clinic and Physician Office
Clinical Care Providers - Nursing and Residential Care Facilities
Clinical Care Providers - Outpatient Care Centers
Clinical Care Providers - Home Health Care Services
Clinical Care Providers - Urgent Care Center
Clinical Care Providers - Rehabilitation Center
Clinical Care Providers - Mental Health Facility
Diagnostic and Laboratory Services - Medical Laboratory
Diagnostic and Laboratory Services - Imaging Center
Diagnostic and Laboratory Services - Pathology and Radiology Services
Pharmaceutical Services - Retail
Pharmaceutical Services - Drug Development
Pharmaceutical Services - Drug Manufacturer
Therapeutic Services - Physical Therapy Provider
Therapeutic Services - Occupational Therapy Provider
Therapeutic Services - Speech therapy provider
Therapeutic Services - Alternative Medicine (Homeopathy, Acupuncture, Herbal therapy, etc.)
Therapeutic Services - Nutrition and Dietetics
Public Health and Community Services - Vaccination
Public Health and Community Services - Disease Surveillance
Public Health and Community Services - Public Health Education
Healthcare Service Authority
Regulatory Body
Training and Educational Institution
Other, please be specific
Please briefly describe the services and/or products provided by your organization/ business
0/500
I am interested in
Hiring a new staff with the Wage Subsidy incentive from ACCEP-IEHP.
Hiring a new staff without the Wage Subsidy incentive from ACCEP-IEHP.
Presenting an online session about the services provided by your organization/business.
By submitting this form, I consent and acknowledge the terms and conditions of the organization.
*
I agree
Print Name
*
Date
*
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit
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