Savin | Visa & Immigrations

Call Anytime
+ 1 ( 437 ) 221-5085

Book a Consultations

Assessment Form

1. Personal Information

First Name & Middle Name:

Last Name at birth:

Last Name after marriage, if applicable:

Sex:

Date of Birth:

Place of Birth (city and country):

Citizenship:

Native Language:

Complete Address of Current Residence with Postal code:

Cell Ph#:

Email Address:

Passport No.:

Date of Issue:

Date of Expiry:

What is your Current Status (Studying / Working / Unemployed / Other)?:

2. Family Composition

Present Marital Status:

Date of Marriage:

Have you been Married more than once (if yes, give details)?

Your Height in cms:

Color of your Eyes:

Name of the Relative in Canada:

Relation to you:

Address in Canada:

Status in Canada:

DETAILS of Children (if any) :

Full Name (as per passport)	Date of Birth	Place of Birth (city and country)	Marital Status	Present Occupation	Action

Present Address	Number of years of completed education	Accompanying you or not

3. Your Education Details of Secondary and post Secondary: ONLY LIST COMPLETED EDUCATION.

Give number of years of completed years:

Elementary school –Total # of years:

Secondary/High School - Total # of years:

College/University - Total # of years:

Diploma or Trade school - Total # of years:

Ielts

Pte

Celpip

Wes

Iqas

Icas

(Please give all the information correctly and with full details. Do not use short forms for the diploma or degree)

** If you require Professional registration/license to practice your profession provide the FIRST date of registration: mm/dd/yy:

From YY/MM/DD	To YY/MM/DD	Academic & Professional Qualification	Specialization	Name of School/University (City and Country where you studied)	Full Time or Part Time	Action

Primary language of instruction for studies:

4. Personal History: Provide the details of your personal history since theage of 18, or past 10 years whichever comes first. If you were/are not working fill as studying or unemployed or travelling etc.Start with the most recent and go backwards. Please ensure that thereis no gap in the dates.

From YY/MM/DD	To YY/MM/DD	Activity in Detail (Job title required)	City/Town & COUNTRY	STATUS IN COUNTRY	Name of employer / School etc as applicable	Action

5 - List every place where you have lived in since theage of 18 or past 10 years whichever is earlier.

From YY/MM/DD	To YY/MM/DD	Activity in Detail (Job title required)	City/Town & COUNTRY	STATUS IN COUNTRY	Name of employer / School etc as applicable	Action

6 - Work History

Total number of years of experience with complete history of ONLY past 10 years:

VERY IMPORANT: In the last column, pleasestart with number of hours per week, Job title and Principal Tasks performed during the work. Do not use abbreviations

From YY/MM/DD	To YY/MM/DD	Name of the Company and (city & Country of employment)	Designation (job title) and Job duties andnumber of hours per week *	FOR EXPRESS ENTRY WORK EXPERINCE PLEASE FILL THE NOC CODE FOR EACH JOB	Action

7 - Family Details

Please give details of your:

Spouse

Parents

Children (if any), (include stepchildren, if any)

Brothers and Sisters (include stepbrothers/sisters)

Marital Status should contain Married, Divorced, Widowed etc.

Middle initials should be expanded do NOT use abbreviations

If deceased, please write date of death & name of city where deceased.

Name	Relationship	Date of Birth (D/M/Y)	Place of Birth	Marital Status	Present Address	Present Occupation	Action

8. DETAILS OF MEMBERSHIP WITH ANY ORGANIZATION (IF APPLICABLE)

PERIOD (FROM AND TO) MM/YYYY	NAME OF ORGANIZATION	TYPE OF ORGANIZATION	POSITION HELD/ACTIVITIES	CITY AND COUNTRY	Action

9. Have you applied for ANY Canadian Visa before? Yes or No:

- If yes: please provide UCI#

10. Did you work or study in Canada at anytime? Yes or No.

- If yes: please contact your coordinator for further instruction

11. Have you ever been refused a visa or permit for any other country or Canada? (provide refusal letters)

SUPPLEMENTARY INFORMATION

Your travels

List all trips You, Your spouse or common-law partner, Your dependent child 18 years old or older have taken outside your country of origin or of residence in the last ten years (or since your 18th birthday if this was less than ten years ago). Include all trips: tourism, business, training, etc. If you or your family member did not travel outside of your country during this period, please mention as "did not travel".

Day-Month-Year (Start)	Day-Month-Year (End)	Length	Destination (City, Country)	Purpose of Travel	Action

Statutory Questions

Have you ever been convicted of a crime or offence in Canada for which a pardon has not been granted under the Criminal Records Act of Canada?
Have you ever committed, been arrested for, been charged with or convicted of any criminal offence in any country?
Have you ever made previous claims for refugee protection in Canada or at a Canadian visa office abroad, in any other country or countries, or with the United Nations High Commissioner for Refugees (UNHCR) ?
Have you ever been refused refugee status, or an immigrant or permanent resident visa (including Certificat de selection du Quebec (CSQ) or application to the Provincial nominee Program) or visitor or temporary resident visa, to Canada or any other country?
Have you ever been refused a visa or permit, denied entry or ordered to leave Canada or any other country?
Have you ever been involved in an act of genocide, a war crime or in the commission of a crime against humanity?
Have you ever used, planned or advocated the use of armed struggle or violence to reach political, religious or social objectives?
Have you ever been associated with a group that used, uses, advocated or advocates the use of armed struggle or violence to reach political, religious or social objectives?
Have you ever been a member of organization that is or was engaged in an activity that is part of a pattern of criminal activity?
Have you ever been detained, incarcerated, or put in jail?
Have you ever had any serious disease or physical or mental disorder?

DECLARATION

I declare that the information contained in this application and appended documents, if any, is complete and accurate and I will notify the representative of any change in answers given on this form before the submission of application to Immigration Department (CIC), CANADA.

I further acknowledge that by saving this document and sending the same to my legal representative electronically; constitute my consent to use the information.

Applicant’s Name:

Signature:

Date: