Sehr Geehrte KANADA Interessentin
Q U E S T I O N N A I R E
Completed on:______
How did you hear about our company?______
PERSONAL DATA AND CONTACT INFORMATIONFamily name / Given name / Name at birth / Current marital status / Date, month, year of the marriage
Specify a previous marriage (if applicable) / Name of previous spouse or partner / Date of birth / Duration of relationship (from-till)
Principal Applicant
Spouse
Family members, who will accompany you to Canada
(including the principal applicant).
Family name / Given name / Date of birth
Day/Month/Year / Place of birth (town, city) / Country of birth / Relationship (daughter, son, step- son and so on) / Citizenship
Family members, who will not be accompanying you to Canada
(including children from a previous marriages, adopted children, children who are married).
Family name / Given name / Date of birth
Day/Month/Year / Place of birth (town, city) / Country of birth) / Relationship (daughter, son, step- son and so on) / Marital status / Residence
(Town & Country)
Current address
Street, House number / Postal code / City / Country
Telephone number / E-mail / Skype
LANGUAGE PROFICIENCY
How would you rate your English and French knowledge on a scale of 0-10?
(0 - no knowledge, 10 - fluent)
Languages / Principal
applicant / Spouse / 1st Child
Name: / 2nd Child
Name:: / 3rd Child
Name: / 4th Child
Name: / 5th Child
Name:
English
French
Native language
EDUCATION
Post-Secondary Education/ Vocational Training/ Continuous Education (please fill out completely)
PRINCIPAL APPLICANT
From
month/year / To
month/year / Name of institution / City and country / Type of certificate or diploma issued / Field of study
SPOUSE
From
month/year / To
month/year / Name of institution / City and country / Type of certificate or diploma issued / Field of study
CHILDREN
Name / Grade / Name / Grade
EMPLOYMENT
Please state your work history since the age of 18 or the past 10 years, whichever is most recent: (e.g. apprenticeship, work, military service, unemployment, etc.). Your time line should be consistent and without any gaps. If you had time off between jobs for whatever reason, indicate the dates and state the reason.
PRINCIPAL APPLICANT
From
month/year / To
month/year / Name of company, employer, school, facility / City or town and country / Activity
SPOUSE
From
month/year / To
month/year / Name of company, employer, school, facility / City or town and country / Activity
Have you, or any of your family members listed in your application for permanent residence in Canada, ever
(If your answer to any of these questions is YES, provide the detailed explanation on a separate sheet of paper)
Been in Canada
If yes, please provide details: period from______to ______; place:______purpose:______ / Yes / No
Been convicted of a crime or offence in Canada for which a pardon has notbeen granted under the Criminal Records Act of Canada? / Yes / No
Been convicted of, or are you currently charged with, on trial for, or party to a crime or offence, or subject of any criminal proceedings in any other? / Yes / No
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)? / Yes / No
Been refused refugee status, an immigrant or permanent resident visa (including a 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? / Yes / No
Been refused admission to, or ordered to leave, Canada or any other country? / Yes / No
Been involved in an act of genocide, a war crime or in the commission of a crime against humanity? / Yes / No
Used, planned or advocated the use of armed struggle or violence to reach political, religious or social objectives? / Yes / No
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? / Yes / No
Been member of an organization that is or was engaged in an activity that is part of a pattern of criminal activity? / Yes / No
Been detained, incarcerated or put in jail? / Yes / No
Had any serious disease or physical or mental disorder? / Yes / No
Have dual citizenship? / Yes / No
Have relatives, friends or acquaintance in Canada? If “yes”, please provide the name,
A address and telephone number:______ / Yes / No
Pleaseuse thisspacetoprovide additionalinformation that youwould likewe to know about you andyour familyor to ask questionsabout immigrationto Canada:
