Please enter your E-mail Address, if any.

My E-mail Address is
Yes No I consent to use of my E-mail Address for communication on my file.

1. Names
   

   	Full Name				Required
   	Other Names

2. Sex Male Female
    
3. My Date and Place of Birth are
   

   	DD/MM/YY
   	City or Town
   	Country

   
   
4. I am a Citizen of
    
5. My Permanent Home Address is
   
    
6. My Current Mailing Address is the Same As Item 5 OR
   
   
   

   	Home Telephone Number
   	Home FAX Number
   	The best time to telephone me (Pacific Standard Time) is between		and .
   	Work Telephone Number
   	Work FAX number
   	You have my permission to telephone me at work.		Yes No

7. My Present Marital Status is: Never Married Engaged Married Widowed Separated Divorced
   

   I am in a same-sex relationship. No Yes

   I am in an opposite-sex (unmarried) relationship. No Yes

   When did the relationship commence? (Please enter a specific date.)

   If you are living together, what date did you start living together? If your partner/spouse is not a Canadian citizen or permanent resident of Canada, they must also complete an assessment questionnaire, even if you will be the principal applicant.

8. Personal Details on All My Dependents (Start with Spouse, Same-Sex or Opposite-Sex Partner in Item 7.)
   

   		Family Name	First Name	Citizen of	Date of Birth DD/MM/YY	Marital Status	Relationship to me	To accompany me to Canada
   A						Never Married Engaged Married Widowed Separated Divorced		No Yes
   B						Never Married Engaged Married Widowed Separated Divorced		No Yes
   C						Never Married Engaged Married Widowed Separated Divorced		No Yes
   D						Never Married Engaged Married Widowed Separated Divorced		No Yes
   E						Never Married Engaged Married Widowed Separated Divorced		No Yes
   F						Never Married Engaged Married Widowed Separated Divorced		No Yes

9. Language Abilities
   

   			Ability in English		Ability in French
   	Speak		No Proficiency Basic Proficiency Moderate Proficiency High Proficiency		No Proficiency Basic Proficiency Moderate Proficiency High Proficiency
   	Read		No Proficiency Basic Proficiency Moderate Proficiency High Proficiency		No Proficiency Basic Proficiency Moderate Proficiency High Proficiency
   	Write		No Proficiency Basic Proficiency Moderate Proficiency High Proficiency		No Proficiency Basic Proficiency Moderate Proficiency High Proficiency
   	Listen		No Proficiency Basic Proficiency Moderate Proficiency High Proficiency		No Proficiency Basic Proficiency Moderate Proficiency High Proficiency

10. My Education (Indicate your highest level of education successfully completed.)

    	Did not complete secondary school (also called high school).
    	Obtained a secondary school credential.
    	Obtained a one-year diploma, trade certificate or apprenticeship and completed at least 12 years of full-time or full-time equivalent studies.
    	Obtained a one-year diploma, trade certificate or apprenticeship and completed at least 13 years of full-time or full-time equivalent studies.
    	Obtained a one-year university degree at the bachelor's level and completed at least 13 years of full-time or full-time equivalent studies.
    	Obtained a two-year diploma, trade certificate or apprenticeship and completed at least 14 years of full-time or full-time equivalent studies.
    	Obtained a university degree of two years or more at the bachelor's level and completed at least 14 years of full-time or full-time equivalent studies.
    	Obtained a three-year diploma, trade certificate or apprenticeship (other than university) and completed at least 15 years of full-time or full-time equivalent studies.
    	Obtained two or more university degrees at the bachelor's level and completed at least 15 years of full-time or full-time equivalent studies.
    	Obtained a master's or Ph.D. and completed at least 17 years of full-time education or full-time equivalent studies.

     
11. Details of my Post-Secondary Education

    	Dates From MM/YY To MM/YY	Name of Institution (Including Apprenticeship Training)	City and Country	Type of Certificate or Diploma Issued

12. Information About My Present Occupation
    

    	Occupation Title
    	Current Gross Monthly Earnings
    	Job Description or List of Duties (i.e. What exactly do you do? Please describe in detail.)

13. My Intended Occupation in Canada  
     
14. My Work History for the Past 10 Years
    

    	Dates From MM/YY To MM/YY	Name of Employer	City and Country	My Occupation

15. Spouse's Occupation/Education
    Present Occupation of My Spouse, Same-Sex or Opposite Sex Partner
    Certificates/Diplomas for My Spouse, Same-Sex or Opposite Sex Partner  
     
16. Work History of my Spouse, Same-Sex or Opposite Sex Partner for the past 10 years
    

    Dates From MM/YY To MM/YY	Name of Employer	City and Country	Occupation

17. Name(s) and Address(es) of Any Relatives, Spouse, Same-Sex or Opposite Sex Partner who are Permanent Residents or Citizens of Canada
     
     
18. Relationship to me of Person(s) Named in Item 17
     
     
19. Destination in Canada
    

    	Name of City/Town
    	Province

20. I have the following Assets (Show Net Amount or Value):
    

    	Transferable Money
    	Property
    	Transferable Pension
    	Other
    	If "Other", give details here.

21. Have you or has any one of the persons in Item 8 ever...
    

    	A		Had any serious disease or mental disorder?		No Yes
    	B		Been convicted of or currently charged with any crime or offence in any country?		No Yes
    	C		Applied previously for an Immigrant Visa to Canada?		No Yes
    	D		Been refused an Immigrant Visa to Canada?		No Yes
    	E		Been staying in Canada or any other country without legal status?		No Yes
    			If answer to any of the above is "Yes", provide details here.

22. Investors
    

    	Do you have a net worth of CAD $800,000.00 and are you prepared to invest CAD $400,000.00 in a government investor program?		No Yes

23. Businessmen
    

    	Do you plan to open a business in Canada?		No Yes
    	If the answer is "Yes", what type of business?
    	Have you previously owned or actively managed a business?		No Yes
    	If the answer is "Yes", provide details.

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