Free Immigration Evaluation Questionnaire

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YOU

Contact Information:
	Last name
	First name
	Middle name(s)
	Sex	Male Female
	E-mail address
	Telephone
	Facsimile
	Street address
	City
	Country
	Postal code
	Birthdate (dd/mm/yyyy): (Example: 14/03/1975)
	Present Occupation:
	Citizenship:
	Marital Status:	Single Engaged Married Separated Divorced Widowed

English Language Ability:

		Speak	Read	Write
	Fluently
	Well
	With Difficulty
	Have you written an English test?	Yes No
	If so, which English test?

Other Languages:
	Please Specify:

Education:
	Primary Secondary University

Degrees, Diplomas or Certificates:
	First Program Start Date: (dd/mm/yyyy)
	First Program Finish Date: (dd/mm/yyyy)
	Name of Diploma, Degree or Certificate Granted:

	Second Program Start Date: (dd/mm/yyyy)
	Second Program Finish Date: (dd/mm/yyyy)
	Name of Diploma, Degree or Certificate Granted:

	Third Program Start Date: (dd/mm/yyyy)
	Third Program Finish Date: (dd/mm/yyyy)
	Name of Diploma, Degree or Certificate Granted:

	Additional Degrees, Diplomas or Certificates:

Professional Training or Apprenticeship:
	Start Date (dd/mm/yyyy):
	Finish Date (dd/mm/yyyy):
	Title or Description of Training:

	Start Date (dd/mm/yyyy):
	Finish Date (dd/mm/yyyy):
	Title or description of Training:

	Start Date (dd/mm/yyyy):
	Finish Date (dd/mm/yyyy):
	Title or Description of Training:

	Title or Description of Other Training:

Personal Information:
	Type of work you plan to do in Canada:

	Do you have an offer of employment in Canada?	Yes No

	If yes, is the offer:	Written Oral Both

	Amount of money you would be bringing to Canada:	Arrival: Later:

	Where do you plan to reside in Canada?

	Have you ever visited Canada before?	Yes No

	If yes, how long was your stay?

	Have you ever visited Quebec before?	Yes No

	If yes, how long was your stay?

	Do you have friends and/or relatives in Canada?	Yes No

	If yes, specify: name, address and occupations:

	Have you previously applied for admission into Canada?	Yes No

	Have you been convicted of or are you currently charged with any crime or offense in any country?	Yes No

	Do you suffer from any communicable or chronic diseases? (exclude common colds or influenza)	Yes No

YOUR SPOUSE

Other Languages:
	Please Specify:

Education:
	Primary Secondary University

Degrees, Diplomas or Certificates:
	First Program Start Date: (dd/mm/yyyy)
	First Program Finish Date: (dd/mm/yyyy)
	Name of Diploma, Degree or Certificate Granted:

	Second Program Start Date: (dd/mm/yyyy)
	Second Program Finish Date: (dd/mm/yyyy):
	Name of Diploma, Degree or Certificate Granted:

	Third Program Start Date: (dd/mm/yyyy)
	Third Program Finish Date: (dd/mm/yyyy)
	Name of Diploma, Degree or Certificate Granted:

	Additional Degrees, Diplomas or Certificates:

Professional Training or Apprenticeship:
	Start Date (dd/mm/yyyy):
	Finish Date (dd/mm/yyyy):
	Title or description of Training:

	Start Date (dd/mm/yyyy):
	To (dd/mm/yyyy):
	Title or description of Training:

	Start Date (dd/mm/yyyy):
	Finish Date (dd/mm/yyyy):
	Title or Description of Training:

	Title or Description of Other Training:

YOUR DEPENDANT(S)

Additional Dependents:

OTHER INFORMATION

Additional Comments:
	Please provide us with any additional information about you or your dependents which you think will be helpful for us to assess your qualifications:

Preferred Communication:

Method:

Best Time to Contact You:

From:
To: