| Assessment Questionnaire |
| Type of service interested
in: |
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| PART 1 - Principle Applicant – Personal
Information |
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| Title: |
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| Surname (Family Name): |
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| Given Name: |
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| Sex: |
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| Current Address: |
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| Phone Number: (area code): |
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| Cell Phone: |
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| Business Phone: |
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| Email Address: |
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| How long resident in this country? |
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| List other Countries Where You Have Resided
for 6 months or more. |
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| Marital Status? |
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| Have you previously been Married
or in a Common-Law Relationship? |
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| Where do you intend to live in
Canada if accepted?: |
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| Education Info |
| Give the number of years of school
you successfully completed for the following? |
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| Elementary/Primary School: |
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| Secondary/High School: |
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| University/College: |
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| Trade School/Other: |
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| List all Certificate/Diploma/Degree Received: |
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| Applicant – Language
Information |
| Which is your first official language? |
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| Which is your second official
language? |
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| What is your proficiency in english? |
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| What is your proficiency in French? |
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| PART 2 – Information
about Spouse / Common-Law Partner |
| Surname (Family Name): |
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| Given Name: |
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| What is your partner's gender? |
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| Is this address the same as the
Principle Applicant? |
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| If the answer is no, please explain. |
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| List other countries where you
have resided for 6 months or more: |
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| Spouse – Language
Information |
| Which is your spouse's first official
language? |
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| Which is your spouse's second
official language? |
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| What is your spouse's proficiency
in english? |
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| What is your spouse’s proficiency
in French? |
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| PART 3 – Details
of Family Members |
| List all family members here including your children,
your spouse/partner’s children even if they will not be accompanying
you. |
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| PART 4 – Additional Information
from Applicant and Spouse/Partner |
| Do you have an Application for
Permanent Residence being processed by Citizenship and Immigration
Canada?: |
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| Do you have a job offer from a prospective Canadian
Employer? |
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| If yes, provide details as to
the employer, occupation etc. |
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| Do you have a HRDC confirmed offer of employment
in Canada? |
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| Do you have any relatives that are Canadians or Permanent
Residents? |
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If yes, provide the following
details:
Name, Relationship, Address, Phone/Email and Status |
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| Other Questions |
| Have you or your spouse/partner
or any of your dependents ever: |
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| Had any serious disease or physical or mental disorder? |
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| Been convicted of or currently charged with any crime
or offence in any country? |
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| Applied previously for a temporary work visa in Canada? |
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| Been refused a Canadian immigrant visa or temporary
permit or that of any other country in the past? |
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| Been refused admission to, or ordered to leave Canada
or any other country? |
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| Been involved in the commission
of a war crime or a crime against humanity? |
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| Applied for refugee status in
any country? |
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| If you answered yes to any of the above questions,
please provide details. |
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