ACCEP-IEHP Employer Registration Form

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

CityProvince

Postal Code
Website
Primary Contact Details*

First NameLast Name
Job Title*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Extension (If applicable)
Organization/Business Size (Total Number of Employees in your Branch/Location)*

1 - 1011 - 5051 – 500501 +
Type of Organization/Business*

PrivatePublicNot for ProfitOther, specify
Service Area (Please choose the service area of your organization/business and check all that applies)*

Clinical Care Providers - HospitalClinical Care Providers - Clinic and Physician OfficeClinical Care Providers - Nursing and Residential Care FacilitiesClinical Care Providers - Outpatient Care CentersClinical Care Providers - Home Health Care ServicesClinical Care Providers - Urgent Care CenterClinical Care Providers - Rehabilitation CenterClinical Care Providers - Mental Health FacilityDiagnostic and Laboratory Services - Medical LaboratoryDiagnostic and Laboratory Services - Imaging CenterDiagnostic and Laboratory Services - Pathology and Radiology ServicesPharmaceutical Services - RetailPharmaceutical Services - Drug DevelopmentPharmaceutical Services - Drug ManufacturerTherapeutic Services - Physical Therapy ProviderTherapeutic Services - Occupational Therapy ProviderTherapeutic Services - Speech therapy providerTherapeutic Services - Alternative Medicine (Homeopathy, Acupuncture, Herbal therapy, etc.)Therapeutic Services - Nutrition and DieteticsPublic Health and Community Services - VaccinationPublic Health and Community Services - Disease SurveillancePublic Health and Community Services - Public Health EducationHealthcare Service AuthorityRegulatory BodyTraining and Educational InstitutionOther, 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*

MonthDayYear
Date
Please verify that you are human*
Should be Empty: