HOWARD P. EISENBERG BARRISTER, SOLICITOR & NOTARY PUBLIC 105 Main Street East, Suite 1010 Hamilton, Ontario, Canada L8N 1G6 Tel: 1 (905) 527-7981 Fax: 1 (905) 529-7791 E-mail: assessment@misterhoward.com   IMMIGRANT ASSESSMENT FORM
Please complete ALL of the information below. If the questions does not apply to you, please answer N/A
Date:	Tuesday, January 06 2009
Applicant's Information
Surname:
Given Names:
Sex (M/F):	M / F	Date of Birth:	(Year-Month-Day)
Citizenship:
Marital Status:	- Select Marital Status - Married Never Married Divorced Separated Engaged to be Married Common Law Other (please specify): ->
Number of Children:		Ages of Children:
Telephone:
Fax:
E-mail:
Address:
(If applicable) if married, engaged to be married, common law or other -
Partner's Information
Surname:
Given Names:
Sex (M/F):	M / F	Date of Birth:	(Year-Month-Day)
Citizenship:
If your contact information is different from your partner's, please complete the following information:
Telephone:
Fax:
E-mail:
Address:
Applicant's Employment
Current Occupation:
Job duties and description:
Months of Experience:	Fulltime (f/t):     Part-time (p/t): Ave hrs /wk for p/t months
Previous occupations within the last 10 years and description of duties (please list separately for each one:
	* Leave this field blank if you have had no previous employment
Months of Experience:	Fulltime (f/t):     Part-time (p/t): Ave hrs /wk for p/t months
Partner's Employment
Current Occupation:
Job duties and description:
Months of Experience:	Fulltime (f/t):     Part-time (p/t): Ave hrs /wk for p/t months
Previous occupations within the last 10 years and description of duties (please list separately for each one:
	* Leave this field blank if you have had no previous employment
Months of Experience:	Fulltime (f/t):     Part-time (p/t): Ave hrs /wk for p/t months
Applicant's Education
Total Number of Years:
Level of Education (please indicate all which apply):
	High or Secondary School		Yes / No
	1 Year Diploma, Trade Cert. or Apprenticeship		Yes / No
	2 Year Diploma, Trade Cert. or Apprenticeship		Yes / No
	3 Year Diploma, Trade Cert. or Apprenticeship		Yes / No
	1 Year University Degree		Yes / No
	2+ Years University Degree		Yes / No
	2+ University Degrees at Bachelor Level		Yes / No
	Master's or Ph.D. Degree		Yes / No
Partner's Education
Total Number of Years:
Level of Education (please indicate all which apply):
	High or Secondary School		Yes / No
	1 Year Diploma, Trade Cert. or Apprenticeship		Yes / No
	2 Year Diploma, Trade Cert. or Apprenticeship		Yes / No
	3 Year Diploma, Trade Cert. or Apprenticeship		Yes / No
	1 Year University Degree		Yes / No
	2+ Years University Degree		Yes / No
	2+ University Degrees at Bachelor Level		Yes / No
	Master's or Ph.D. Degree		Yes / No
Applicant's Language Proficiency
Are you more proficient in English or French?	English French
Ability in English:	Speak:  High Moderate Basic None Read:  High Moderate Basic None Write:  High Moderate Basic None Listen:  High Moderate Basic None
Ability in French:	Speak:  High Moderate Basic None Read:  High Moderate Basic None Write:  High Moderate Basic None Listen:  High Moderate Basic None
Have you taken an English or French language test? If yes, provide details:
Partner's Language Proficiency
Are you more proficient in English or French?	English French
Ability in English:	Speak:  High Moderate Basic None Read:  High Moderate Basic None Write:  High Moderate Basic None Listen:  High Moderate Basic None
Ability in French:	Speak:  High Moderate Basic None Read:  High Moderate Basic None Write:  High Moderate Basic None Listen:  High Moderate Basic None
Have you taken an English or French language test? If yes, provide details:
Applicant/Partner Questionnaire
Have you or your partner arranged for employment in Canada? Yes / No If yes, provide details:
Have you or your partner ever studied in Canada? Yes / No If yes, provide details:
Have you or your partner ever worked in Canada? Yes / No If yes, provide details:
Funds available to transfer to Canada: $ USD equivalent
Do you or your partner have any relatives in Canada? Yes / No If yes, provide relationship (e.g. my partner's mother's sister, name and address, phone, fax, email):
Have you or your partner, or any dependant had:
a.  any serious disease or mental disorder? Yes / No b.  a criminal charge, conviction or commission Yes / No c.  applied previously for immigration/visitor visa to Canada Yes / No d.  been refused visa, admission or ordered to leave Canada or any country Yes / No If you answered yes to a,b,c, or d, please provide details:
How did you hear about us?
Thank you...
Thank you for your interest in our firm. Please write any additional information you believe we should know about. Once we receive the form from you we shall examine the information and provide you with our comments. Please be patient. We normally respond within 72 hours, however this may vary during peak times, business travel or vacation periods.
Copyright © 2000 Howard P. Eisenberg. All rights reserved.
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