Our Free Immigration Assessment

This form is for our own use only. In order to succeed in obtaining a temporary or permanent resident permit for Canada, it is important to answer all questions fully and truthfully. Information collected will be strictly kept confidential, and will not be used in mailing lists.

Applicant:

First Name	Last Name

Street Address Line 1	Referred by

Street Address Line 2

City	State/Province

Country

Zip/Postal Code

Tel (home)		email
( )
Tel (office)		Fax
( )		( )
Birthdate (dd-mm-yy)		Citizenship

Language Ability:

English:	French:
Fluent Fair With difficulty Not at all	Fluent Fair With difficulty Not at all

Education:

High School	years	Formal Training	years
College/University	years	Major of study

Employment History:

	Period	Position	Job Duties
1.
2.
3.
4.
5.

Spousal Information:

First Name	Last Name

Birthdate (dd-mm-yy)	Citizenship

Language Ability:

English:	French:
Fluent Fair With difficulty Not at all	Fluent Fair With difficulty Not at all

Education:

High School	years	Formal Training	years
College/University	years	Major of study

Employment History:

	Period	Position	Job Duties
1.
2.
3.
4.
5.

Children:

Child's Name		Date of Birth (dd-mm-yy)
Child's Name		Date of Birth (dd-mm-yy)
Child's Name		Date of Birth (dd-mm-yy)

Personal Financial Information:

Net personal worth (US$)

Cash
Real Estate
Other Assets

Business Financial Information (US$)

What % of shares do you own?	Number of employees

Annuals Sales	Annual Net Income

Net Business Assets

Other Important Information:

Contact person in Canada or U.S.
First Name	Last Name

Phone Number
( )
Do you or your spouse have relative in Canada? Yes No		Relationship

Have you or your spouse studied or worked in Canada?
Yes
No

If yes,

Period (From: dd-mm-yy. To: dd-mm-yy)

Purpose

Can you or your spouse secure a job offer from a Canadian Employer?
Yes
No

Have you or any of your dependants ever:

Had any serious disease or mental disorder?
yes
no
Been convicted or are currently charged with any crime or offence in any country?
yes
no
Applied previously for an immigrant visa to Canada?
yes
no
Been refused an immigrant visa to Canada or any other country?
yes
no
Been refused admission or ordered to leave Canada or any other country?
yes
no

I hereby certify that all of the information I have provided above is true.

Date (dd-mm-yy)