ASSESSMENT FORM

    Personal Information

    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):

    Language Proficiency



    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?

    SingleMarriedSeparatedDivorced

     

     

     

    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?

    YesNo

    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)

     

     

    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)

     

    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.

    YesNo

    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:

    YesNo

    Been convicted of, or currently subject to any criminal proceeding in any country?

    YesNo

    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)?

    YesNo

    Been denied refugee status, OR any type of visa (e.g. immigrant, permanent resident, visitor, temporary resident) in Canada or any other country?

    YesNo

    Been refused admission to or ordered to leave Canada OR any other country?

    YesNo

    Been involved in an act of genocide, a war crime, a crime against humanity, or the desecration of religious property?

    YesNo

    Used, use or plan to use violence as an end to achieve political, social or religious objectives?

    YesNo

    Been a member of a group that is or was involved with organized crime?

    YesNo

    Had any serious diseases or physical or mental disorders?

    YesNo

     

    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.


    We will help to find the perfect place for you!