IELTS or CELPIP?
Date of Test (day/month/year)
General or Academic?
Name of School / Institute
Type of Certification / Diploma / Degree Issued
Name of Employer & Address
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?
First Name (given name)
Last Name (surname)
Date of Birth (day/month/year)
Country of Birth
Country of Residence
---AD - AndorraAE - United Arab EmiratesAF - AfghanistanAG - Antigua and BarbudaAI - AnguillaAL - AlbaniaAM - ArmeniaAO - AngolaAQ - AntarcticaAR - ArgentinaAS - American SamoaAT - AustriaAU - AustraliaAW - ArubaAZ - AzerbaijanBA - Bosnia and HerzegovinaBB - BarbadosBD - BangladeshBE - BelgiumBF - Burkina FasoBG - BulgariaBH - BahrainBI - BurundiBJ - BeninBL - Saint BarthelemyBM - BermudaBN - BruneiBO - BoliviaBR - BrazilBS - Bahamas, TheBT - BhutanBV - Bouvet IslandBW - BotswanaBY - BelarusBZ - BelizeCA - CanadaCC - Cocos (Keeling) IslandsCD - Congo, Democratic Republic of theCF - Central African RepublicCG - Congo, Republic of theCH - SwitzerlandCI - Cote d'IvoireCK - Cook IslandsCL - ChileCM - CameroonCN - ChinaCO - ColombiaCR - Costa RicaCU - CubaCV - Cape VerdeCW - CuracaoCX - Christmas IslandCY - CyprusCZ - Czech RepublicDE - GermanyDJ - DjiboutiDK - DenmarkDM - DominicaDO - Dominican RepublicDZ - AlgeriaEC - EcuadorEE - EstoniaEG - EgyptEH - Western SaharaER - EritreaES - SpainET - EthiopiaFI - FinlandFJ - FijiFK - Falkland Islands (Islas Malvinas)FM - Micronesia, Federated States ofFO - Faroe IslandsFR - FranceFX - France, MetropolitanGA - GabonGB - United KingdomGD - GrenadaGE - GeorgiaGF - French GuianaGG - GuernseyGH - GhanaGI - GibraltarGL - GreenlandGM - Gambia, TheGN - GuineaGP - GuadeloupeGQ - Equatorial GuineaGR - GreeceGS - South Georgia and the IslandsGT - GuatemalaGU - GuamGW - Guinea-BissauGY - GuyanaHK - Hong KongHM - Heard Island and McDonald IslandsHN - HondurasHR - CroatiaHT - HaitiHU - HungaryID - IndonesiaIE - IrelandIL - IsraelIM - Isle of ManIN - IndiaIO - British Indian Ocean TerritoryIQ - IraqIR - IranIS - IcelandIT - ItalyJE - JerseyJM - JamaicaJO - JordanJP - JapanKE - KenyaKG - KyrgyzstanKH - CambodiaKI - KiribatiKM - ComorosKN - Saint Kitts and NevisKP - Korea, NorthKR - Korea, SouthKW - KuwaitKY - Cayman IslandsKZ - KazakhstanLA - LaosLB - LebanonLC - Saint LuciaLI - LiechtensteinLK - Sri LankaLR - LiberiaLS - LesothoLT - LithuaniaLU - LuxembourgLV - LatviaLY - LibyaMA - MoroccoMC - MonacoMD - MoldovaME - MontenegroMF - Saint MartinMG - MadagascarMH - Marshall IslandsMK - MacedoniaML - MaliMM - BurmaMN - MongoliaMO - MacauMP - Northern Mariana IslandsMQ - MartiniqueMR - MauritaniaMS - MontserratMT - MaltaMU - MauritiusMV - MaldivesMW - MalawiMX - MexicoMY - MalaysiaMZ - MozambiqueNA - NamibiaNC - New CaledoniaNE - NigerNF - Norfolk IslandNG - NigeriaNI - NicaraguaNL - NetherlandsNO - NorwayNP - NepalNR - NauruNU - NiueNZ - New ZealandOM - OmanPA - PanamaPE - PeruPF - French PolynesiaPG - Papua New GuineaPH - PhilippinesPK - PakistanPL - PolandPM - Saint Pierre and MiquelonPN - Pitcairn IslandsPR - Puerto RicoPS - Gaza StripPS - West BankPT - PortugalPW - PalauPY - ParaguayQA - QatarRE - ReunionRO - RomaniaRS - SerbiaRU - RussiaRW - RwandaSA - Saudi ArabiaSB - Solomon IslandsSC - SeychellesSD - SudanSE - SwedenSG - SingaporeSH - Saint Helena, Ascension, and Tristan da CunhaSI - SloveniaSJ - SvalbardSK - SlovakiaSL - Sierra LeoneSM - San MarinoSN - SenegalSO - SomaliaSR - SurinameSS - South SudanST - Sao Tome and PrincipeSV - El SalvadorSX - Sint MaartenSY - SyriaSZ - SwazilandTC - Turks and Caicos IslandsTD - ChadTF - French Southern and Antarctic LandsTG - TogoTH - ThailandTJ - TajikistanTK - TokelauTL - Timor-LesteTM - TurkmenistanTN - TunisiaTO - TongaTR - TurkeyTT - Trinidad and TobagoTV - TuvaluTW - TaiwanTZ - TanzaniaUA - UkraineUG - UgandaUM - United States Minor Outlying IslandsUS - United StatesUY - UruguayUZ - UzbekistanVA - Holy See (Vatican City)VC - Saint Vincent and the GrenadinesVE - VenezuelaVG - British Virgin IslandsVI - Virgin IslandsVN - VietnamVU - VanuatuWF - Wallis and FutunaWS - SamoaXK - KosovoYE - YemenYT - MayotteZA - South AfricaZM - ZambiaZW - Zimbabwe
Country of Issue
Date of Issue (day/month/year)
Date of Expiry (day/month/year)
Do you have any children?
How many children do you have?
If you have children, include their names and ages below
City and Country
Purpose of Trip
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?
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?
*Separate forms are required to be filled by each person, in case of married or in a common law relationship.