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Assessment Form

Please complete the form below to the best of your ability to obtain a more accurate assessment of your chances to visit, study, or work in Canada. This form can only be filled out electronically.

Before you go any further...

Criminality (if applicable)

Have you ever been convicted of a crime?
Yes
No

Date of incident (YYYY/MM/DD):

Please provide a brief explanation:

Associations (if applicable)

Have you ever been a member of any association in favor of relations - either cultural or economical - between your country and Canada?
Yes
No

If yes, please indicate from when to when:
From (YYYY/MM/DD):
To (YYYY/MM/DD):

Name of Association:

Type of Association:

Position or Title held:

Address (including postal code and country):

Education (if applicable)

Highest level of completed education:
High School
Trade School
Vocational School
University College

Name of your degree - if applicable (eg. Bachelors of Mechanical Engineering):

Area of specialization:

Years of formal education:

This includes Elementary School, Secondary/High School, University/College, Trade School, and other post-secondary schools.

Residency

Please provide all information for places you have resided for the past 10 years, without gaps.

Residence #1:
From (YYYY/MM/DD): To (YYYY/MM/DD):

Complete Address (including postal code and country):

Residence #2:
From (YYYY/MM/DD): To (YYYY/MM/DD):

Complete Address (including postal code and country):

Residence #3:
From (YYYY/MM/DD): To (YYYY/MM/DD):

Complete Address (including postal code and country):

Residence #4:
From (YYYY/MM/DD): To (YYYY/MM/DD):

Complete Address (including postal code and country):

Residence #5:
From (YYYY/MM/DD): To (YYYY/MM/DD):

Complete Address (including postal code and country):

Work Experience (if applicable)

Please complete your work experience in full for the last 10 years:

Job #1 (most recent)
From (YYYY/MM): To (YYYY/MM):
Name of Company: Position: Address (please include country):

Job #2
From (YYYY/MM): To (YYYY/MM):
Name of Company: Position: Address (please include country):

Job #3
From (YYYY/MM): To (YYYY/MM):
Name of Company: Position: Address (please include country):

Job #4
From (YYYY/MM): To (YYYY/MM):
Name of Company: Position: Address (please include country):

Spousal Information (if applicable)

Spouse's First Name:

Spouse's Middle Name:

Spouse's Last Name:

Spouse's Gender: Male Female

Spouse's Date of Birth (YYYY/MM/DD):

Where were you married?

Marriage Date (YYYY/MM/DD):

Spouse's Education (if applicable)

Highest level of completed education:
High School
Trade School
Vocational School
University College

Name of your degree - if applicable (eg. Bachelors of Mechanical Engineering):

Area of specialization:

Years of formal education:

This includes Elementary School, Secondary/High School, University/College, Trade School, and other post-secondary schools.

Spouse's Work Experience (if applicable)

Please complete your spouse's work experience in full for the last 10 years:

Job #1 (most recent)
From (YYYY/MM): To (YYYY/MM):
Name of Company: Position: Address (please include country):

Job #2
From (YYYY/MM): To (YYYY/MM):
Name of Company: Position: Address (please include country):

Job #3
From (YYYY/MM): To (YYYY/MM):
Name of Company: Position: Address (please include country):

Job #4
From (YYYY/MM): To (YYYY/MM):
Name of Company: Position: Address (please include country):

Children (if applicable)

Will your child(ren) by accompanying you: Yes No

Child #1's First Name:

Child #1's Middle Name:

Child #1's Last Name:

Child #1's Gender: Male Female

Child #1's Date of Birth (YYYY/MM/DD):

Child #1's Place of Birth (City/Country):

Child #1's highest level of education completed:

Child #2's First Name:

Child #2's Middle Name:

Child #2's Last Name:

Child #2's Gender: Male Female

Child #2's Date of Birth (YYYY/MM/DD):

Child #2's Place of Birth (City/Country):

Child #2's highest level of education completed:

Arranged Employment

Is there a company in Canada that wants to hire you?
Yes - fill out additional information.
No

If you answered yes, please provide us with additional information about your arrangement:

Relatives in Canada

Do you, or your accompanying spouse (if applicable), have a relative above 18 years of age (parent, grandparent, child, grandchild, brother, sister, aunt, uncle, niece, or nephew) that is currently residing in Canada and is a Canadian citizen or Permanent Resident?
Yes
No

Previous Work or Study in Canada

Have you, or your accompanying spouse (if applicable), completed a minimum of one year of full-time work or study in Canada? Yes
No

If you answered yes, please provide us with additional information about your previous work or study in Canada:

Last Questions...

Additional Comments:

If you have anything additional that you feel we should know, or if you simply have something you'd like to tell us - please include it here.

How would you prefer to be contacted for your consultation?
In-Person
Skype
Phone

How did you hear about us?
Internet Search
CICS News
Newspaper Advertisement
Referral:
Other:

Note

We urge all our clients and prospective clients to use the Internet and the ICCRC website to research and check us and any representative that you may think of employing, for your own protection. Many "ghost" representatives promote their services to unsuspecting clients and are not qualified or Regulated Canadian Immigration Consultants but are in fact just middle men asking for referral fees. Please be sure to check anyone and everyone you deal with is an accredited member of the ICCRC.