Se
nd completed form to Payroll Services:
FAX (250) 755-7621 Nanaimo
Mai
l or Hand Deliver to: 1461 Estevan Road, Nanaimo, BC V9S 3Y3
Scan and Email to: Leave.PayBenefits@viha.ca
Request for Record of Employment
To obtain Employment Insurance Benefits (EI) from
Service Canada
Employee Information: (Please print)
Name of Employee: _____________________________________________________________
Last Name First Name Initial
Employee#(s): ______________________________
Reason for ROE: Please check appropriate box
Reduction in Hours Termination/Retirement
Illness First Day Sick Paid: ________________ Last Day Sick Paid: _________________
(DD/MMM/YYYY) (DD/MMM/YYYY)
Maternity/Parental starting: ____________________________________
(Copy of Leave Request Form required) (DD/MMM/YYYY)
Other (please specify) ________________________________________________________
(Copy of Leave Request Form required)
Last Day Worked: ____________________ (required for all Reasons)
________________________ ___________________ ___________________
Employee Signature Phone Number Date of Request
Completed ROE forms are submitted electronically to Service Canada on your behalf after your last
paid/worked day has been processed.
Request for Record of Employment
To obtain Employment Insurance Benefits (EI) from Service Canada
If the last day worked or last day paid falls within the current pay period, Manager’s approval is required
to verify last day paid.
Department Managers Name (printed): _____________________ Phone#: ______________
___________________________________ _____________________
Department Manager Approval (Signature) Date
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February 21, 2018
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