1. Family Name
2. Given Names
3. Date of Birth Month / Day / Year
4. Sex Male Female
5. Citizenship
6. Country of Residence
7. Marital Status Never Married Married Divorced Widowed Common Law
8. Do you have any children? Yes No
If yes how many children and how old are they
9. Ability in English None Basic Moderate High
10. Ability in French None Basic Moderate High
11. Have you ever taken a language test? Yes No
If yes provide details
12. Mailing Address with City and Country
13. Email Address
14. Primary Phone Number
15. Secondary Phone Number
16. Current Occupation
Job Duties and Description
17. Starting Date of Current Job Month / Year
18. Previous Occupation for the Last 10 Years
19. Starting Date of Previous Job Month / Year
20. Ending Date of Previous Job Month / Year
21. Have You Ever Worked in Canada? Yes No
22. Do You Have a Job Offer in Canada? Yes No
23. Years of Education
24. Highest Level Of Education Achieved Primary School High School College University Masters PhD
25 a. Trade School
25 b. Apprenticeship
26. Do you have a Diploma or a Certificate? Yes No
27. Have You Ever Studied in Canada? Yes No
28. Funds Available to Transfer to Canada in US Dollars
29. Do You Have any Relatives Living in Canada? Yes No
30. Have you or any dependent ever had any serious disease or mental disorder? Yes No
31. Have you or any dependent ever had a criminal charge or conviction? Yes No
32. Have you or any dependent previously applied for an Immigration Visa or Visitor Visa to Canada? Yes No
33. Have you or any dependent ever been refused a visa, admission, or ordered to leave Canada or any country? Yes No
34. Please provide our office with any additional information you believe we should know about in the box below
