Questionnaire/Assessment

Personal Information

First Name:	Family Name:	Gender

Mailing Address:

Telephone:
	Home:	Business:
	Fax:	E-mail:

Date of Birth:

YYYY

Citizenships (list all):

Passport Number:

What would you like to apply for?

Marital Status:

Single

Married

Divorced

Widowed

Common Law

Date of marriage:

Age of children, if any:

Have you, your spouse or your children ever had any serious medical problems?

Do you or your spouse have a criminal record?

Do you or your spouse have relatives who are Canadian Citizens or permanent residents living in Canada? Provide names and relationships (parent, grandparent, aunt, uncle, sibling, niece, nephew, child, grandchild, spouse, common-law partner or conjugal partner).

Have you or your spouse studied or worked in Canada?

Educational Background:

Secondary Education:

Did you complete your secondary education?

Post-secondary Education:

College or university (Name of institution):

Did you obtain a trade certificate? If yes, what profession:

Faculty:
Number of years:
Degree(s):

Work Experience:

Current occupation:

What occupation do you intend to pursue in Canada?

Current and past work history:

FROM	TO	EMPLOYER	POSITION	DUTIES
MM/YYYY	MM/YYYY
MM/YYYY	MM/YYYY
MM/YYYY	MM/YYYY
MM/YYYY	MM/YYYY
MM/YYYY	MM/YYYY

Language Ability:

Please mark appropriately

English
Speak:	Read:	Write:	Listen:
French
Speak:	Read:	Write:	Listen:

What other languages do you speak?

Your finances:

This information will be required by Immigration in order to assess your application.

What is your approximate net worth?

What is your approximate income?

Information About Your Spouse or Life Partner

Information About Your Spouse or Life Partner:

Type of relationship?

First Name:	Family Name:	Gender