Assessment Form

1. Personal Information
2. Family Composition
DETAILS of Children (if any) :
Full Name (as per passport)Date of BirthPlace of Birth (city and country)Marital StatusPresent OccupationAction
Present AddressNumber of years of completed educationAccompanying you or not
3. Your Education Details of Secondary and post Secondary: ONLY LIST COMPLETED EDUCATION.

Give number of years of completed years:


(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/DDTo YY/MM/DDAcademic & Professional QualificationSpecializationName of School/University (City and Country where you studied)Full Time or Part TimeAction

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/DDTo YY/MM/DDActivity in Detail (Job title required)City/Town & COUNTRYSTATUS IN COUNTRYName of employer / School etc as applicableAction
5 - List every place where you have lived in since theage of 18 or past 10 years whichever is earlier.
From YY/MM/DDTo YY/MM/DDActivity in Detail (Job title required)City/Town & COUNTRYSTATUS IN COUNTRYName of employer / School etc as applicableAction
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/DDTo YY/MM/DDName 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 JOBAction
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.
NameRelationshipDate of Birth (D/M/Y)Place of BirthMarital StatusPresent AddressPresent OccupationAction
9. Have you applied for ANY Canadian Visa before? Yes or No:
10. Did you work or study in Canada at anytime? Yes or No.
11. Have you ever been refused a visa or permit for any other country or Canada? (provide refusal letters)
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)LengthDestination (City, Country)Purpose of TravelAction
Statutory Questions
  1. 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?
  2. Have you ever committed, been arrested for, been charged with or convicted of any criminal offence in any country?
  3. 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) ?
  4. 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?
  5. Have you ever been refused a visa or permit, denied entry or ordered to leave Canada or any other country?
  6. Have you ever been involved in an act of genocide, a war crime or in the commission of a crime against humanity?
  7. Have you ever used, planned or advocated the use of armed struggle or violence to reach political, religious or social objectives?
  8. 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?
  9. 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?
  10. Have you ever been detained, incarcerated, or put in jail?
  11. Have you ever had any serious disease or physical or mental disorder?
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: