Step 2 of 5: Personal Information

Contact Information

Name (Surname in CAPITALS) *

Date of Birth *

Sexuality *
MaleFemale

Address (include city and postal code) *

Phone Number *

Other Phone Number

Email Address *

Preferred contact method
EmailPhone

If you prefer to be contacted by phone, can we leave you a voicemail message? *
YesNo

Best time to contact you by phone Before 12 NoonAfter 12 Noon

Ethnicity
Black - North AmericanBlack - Latin AmericanBlack - North AfricanBlack - East AfricanBlack - Indigenous (Afro-Indigenous)Black - CaribbeanBlack - EuropeanBlack - South AfricanBlack - West AfricanBlack - Other

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Step 3 of 5: Income & Assets

Income

Main source of household income
Salary or Employment IncomeEmployment Insurance (EI)British Columbia WorksStudent Assistance ProgramDisability Support ProgramWorkplace Safety InsuranceCanada Pension Plan (CPP)No IncomeOld Age Security (OAS)Other

Monthly income *

Number of people supported by the monthly income *

Number of children under 18 in your household *

Number of adults 18 and above in your household *

Number of members of your household totally dependent on the monthly income (example: elderly parent or family member with disabilities who do not earn their own income) *

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Assets

Real property (land, house or condominium excluding your principal residence) *

Personal property (everything else except land, house or condominium) *

Bank Account / Term Deposit / Credit Union *

Stocks / Bonds / Mortgage / Investments *

Interest in a Business *

Jewelry / Art / Collectibles *

Other Assets (excluding 1 Car, Tools of Trade, Insurance Equity, Furniture in Principle Residence)

I certify that the above financial information is true and correct.

Append Your Signature *

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Step 4 of 5: Language & Accommodation

Preferred language
EnglishFrenchAmharicArabicASLHaitian CreolePortugueseSomaliOther

Organizations like BCBAS are required by appropriate Laws to provide accommodations where required.

Do you need any accommodations? If yes, please tell us what accommodations you need

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Step 5 of 5: Legal Issue

Were you treated unfairly because of your race? *
YesNo

Where did this happen?
Work (Employer, Supervisor, Colleague)School (Teacher, Student, Staff)Housing (Landlord, Tenant)Store or Government ServiceDisability ServicesEmployment servicesIncome SupportCorrectional ServicesPoliceOther

Tell us what happened

Do you have supporting documents? *
YesNo

How would you like this resolved?

Would you like support resources?
YesNo

Would you be willing to provide a brief statement of appreciation for the legal advice/services provided courtesy of the BLEI after you have been provided the services? *
YesNo

Additional Notes

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