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THIS FORM IS NOT ENCRYPTED. USE AT YOUR OWN DISCRETION.

CURRENT INFORMATION

Family Name:

First Name:

Street Address:

City:

State or Province:

Country of Residence:

Postal/Zip Code:

Daytime Telephone:

Alternate Telephone:

Fax Number:

Email:

Past Countries of Residence:

Country of Birth:

City or Town of Birth:

Sex:

Date of Birth:

Maritial Status:

Total Number of Dependents:

#of children 0-12yrs:

# of children 13-21yrs:

EDUCATION

Highest level of Education:

Total years of education, including primary and secondary:

DEGREE

Major:

Name of Insitution:

Location of Institution:

Start Date:

Graduation Date:

did NOT Graduate
Graduated
Graduated with honors/distinction

DEGREE #2

Major:

Name of Insitution:

Location of Institution:

Start Date:

Graduation Date:

I did NOT Graduate
Graduated
Graduated with honors/distinction

EDUCATION - OTHER

please use this space to define any other education information you feel will be of benefit.

LANGUAGES

Language	Fluent	Proficient	with Difficulty	no ability
ENGLISH
FRENCH
				n/a
				n/a

WORK EPXERIENCE

EMPLOYER ONE

Current Occupation:

Name of Company:

Company Mailing Address:

Start Date:

End Date:

Describe your Duties:

EMPLOYER TWO

Previous Occupation:

Name of Company:

Company Mailing Address:

Start Date:

End Date:

Describe your Duties:

EMPLOYER THREE

Previous Occupation

Name of Company:

Company Mailing Address:

Start Date:

End Date:

Describe your Duties:

NET WORTH

Liquid Assets/$CAD:

Property Values/$CAD:

Other Assets/$CAD:

INFORMATION ON SPOUSE
Skip this section if not applicable

Spouse Family/Maiden Name:

Spouse First Name:

Street Address (if different):

City:

State or Province:

Country of Residence:

Postal/Zip Code:

DaytimeTelephone:

Alternate Telephone:

Fax:

E-mail:

Past Countries of Residence:

Country of Birth:

City or Town of Birth:

Sex:

Date of Birth:

Marital Status:

Total Number of Dependents:

#of children 0-12yrs:

# of children 13-21yrs:

SPOUSE EDUCATION

Highest level of Education:

Total years of education, including primary and secondary:

SPOUSES DEGREE #1

Major:

Name of Insitution:

Location of Institution:

Start Date:

Graduation Date:

did NOT Graduate
Graduated
Graduated with honors/distinction

SPOUSES DEGREE #280

Major:

Name of Insitution:

Location of Institution:

Start Date:

Graduation Date:

did NOT Graduate
Graduated
Graduated with honors/distinction

SPOUSES OTHER EDUCATION

please use this space to define any of your spouses other education information you feel will be of benefit.

SPOUSES SPOKEN LANGUAGES

Language	Fluent	Proficient	with Difficulty	no ability
ENGLISH
FRENCH
				n/a
				n/a

SPOUSES WORK EXPERIENCE
EMPLOYER #1

Current Occupation:

Name of Company:

Company Mailing Address:

Start Date:

End Date:

Describe your Duties:

SPOUSES EMPLOYER #2

Previous Occupation:

Name of Company:

Company Mailing Address:

Start Date:

End Date:

Describe your Duties:

SPOUSES EMPLOYER # 3

Previous Occupation:

Name of Company:

Company Mailing Address:

Start Date:

End Date:

Describe your Duties:

BUSINESS - SELF EMPLOYMENT
If Applicable

Please give a brief description regarding your business management and experience.

Please give a brief description regarding your Spouses business management and experience.

ADDITIONAL QUESTIONS
Omissions can cause delays

Do you have a job offer from a prospective Canadian Employer:

YES NO

Do you have an HRSDC confirmed offer of Employment?:

YES NO

Have you or your spouse previously studied or worked in Canada?:

YES NO

Do you have any friends or family who are permanent residents or Canadian Citizens in Canada?:

YES NO

If YES, which province do they reside in Canada?:

ESSENTIAL QUESTIONS
Omissions can cause delays

Have you, your spouse or any of your dependents ever:

Had any serious disease or physical or mental disorder?:

Yes No

Been convicted of or are currently charged with any crime or offense in any country?:

YES NO

Applied previously for Temporary Status in Canada?
example: Student/ Visitor/ Worker?:

YES NO

Been refused any one of the above visas?

YES NO

Been involved in the commission of a war crime or a crime against humanity?

YES NO

Applied previously for Permanent Residence in Canada?

YES NO

If you have answered YES to any of the last 6 questions please provide a brief description:

Please use this space for any additional comments, a list of honorariums, employment, life skills, awards, education, or other information you feel relevent to your case or that will further assist us in streamlining the immigration process.

This online assessment is a preliminary overview which is informational
only. This is not intended to engage in a client agreement nor is it a form
of retained services."

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