User record

Personal Information

First Name:

Middle Name:

Last Name:

Date of Birth:

Sex:

Country of Birth:

Country of Residence:

Passport Number:

Country of Issue:

Date of Issue:

Date of Expiry:

Contact Details

Current Address (Street, Province/State, Postal Code, Country):

Cell Phone (including area code):

Home Phone (including area code):

Email Address:

Language Proficiency

Do you know English?

How well do you speak?

How well do you write?

Do you know French?

How well do you speak?

How well do you write?

What is your native language?

Native language Written and spoken skills:

IELTS or CELPIP?	Ability Category	Results
	Reading
Date of Test (day/month/year)	Writing
	Speaking
General or Academic?	Listening

Personal Education

Name of School / Institute	City/Country	Type of Certification / Diploma / Degree Issued	Year from	Year To

Work Experience

Name of Employer & Address	Job Title	Job Description	Year from	Year To

Marital Status

Marital Status	If married, What day were you married?	If you are in a common-law relationship, what was the date you started living together?	If you are married/in a common law relationship, is your partner immigrating to Canada with you?

Spouse Details

First Name (given name)		Middle Name(s)	Last Name (surname)

Date of Birth (day/month/year)	Sex (male/female)	Country of Birth	Country of Residence

Passport Number		Country of Issue	Date of Issue (day/month/year)	Date of Expiry (day/month/year)

Children Details

Do you have any children?		How many children do you have?
If you have children, include their names and ages below

First Name (given name)		Middle Name(s)	Last Name (surname)

Date of Birth (day/month/year)	Sex (male/female)	Country of Birth	Country of Residence

Passport Number		Country of Issue	Date of Issue (day/month/year)	Date of Expiry (day/month/year)

First Name (given name)		Middle Name(s)	Last Name (surname)

Date of Birth (day/month/year)	Sex (male/female)	Country of Birth	Country of Residence

Passport Number		Country of Issue	Date of Issue (day/month/year)	Date of Expiry (day/month/year)

First Name (given name)		Middle Name(s)	Last Name (surname)

Date of Birth (day/month/year)	Sex (male/female)	Country of Birth	Country of Residence

Passport Number		Country of Issue	Date of Issue (day/month/year)	Date of Expiry (day/month/year)

First Name (given name)		Middle Name(s)	Last Name (surname)

Date of Birth (day/month/year)	Sex (male/female)	Country of Birth	Country of Residence

Passport Number		Country of Issue	Date of Issue (day/month/year)	Date of Expiry (day/month/year)

First Name (given name)		Middle Name(s)	Last Name (surname)

Date of Birth (day/month/year)	Sex (male/female)	Country of Birth	Country of Residence

Passport Number		Country of Issue	Date of Issue (day/month/year)	Date of Expiry (day/month/year)

Parent Details

Father

First Name (given name)		Middle Name(s)	Last Name (surname)

Date of Birth (day/month/year)	Sex (male/female)	Country of Birth	Country of Residence

Passport Number		Country of Issue	Date of Issue (day/month/year)	Date of Expiry (day/month/year)

Mother

First Name (given name)		Middle Name(s)	Last Name (surname)

Date of Birth (day/month/year)	Sex (male/female)	Country of Birth	Country of Residence

Passport Number		Country of Issue	Date of Issue (day/month/year)	Date of Expiry (day/month/year)

Travel History

Please list all international travel in the last ten (10) years

City and Country	Purpose of Trip	From (year/month)	To (year/month)	Visa Issued

Additional Questions

Read the following carefully and truthfully

Indicate whether you have worked/studied/visited/or never been to Canada before	Have you ever had a work or study permit to Canada?	If you lived in Canada before, what were the dates?

List the total amount of funds you have that are legal and transferrable (Do not include equity in real estate).	Do you or your partner have close family members who are permanent residents or citizens of Canada and live in Canada now?	If you answered Yes to the question on the left, please state the relationship of the family member to you/your partner and the name of the city in Canada in which he/she resides.

What province/territory in Canada are you interested in working, studying, or settling in?

	Yes / No	Yes (Provide a detailed explanation in the space below)
Have you or your spouse/partner or dependents ever:
Been convicted of, or currently subject to any criminal proceeding in any country?
Previously sought refugee status in Canada or applied for Canadian immigrant or permanent resident visa OR any other type of visa (e.g. temporary resident or visitor)?
Been denied refugee status, OR any type of visa (e.g. immigrant, permanent resident, visitor, temporary resident) in Canada or any other country?
Been refused admission to or ordered to leave Canada OR any other country?
Been involved in an act of genocide, a war crime, a crime against humanity, or the desecration of religious property?
Used, use or plan to use violence as an end to achieve political, social or religious objectives?
Been a member of a group that is or was involved with organized crime?
Had any serious diseases or physical or mental disorders?
Is there any other information that you feel is important to share as part of your preliminary assessment?

Do you have any specific questions or concerns that you would like addressed in your assessment report?