Please note that this questionnaire is intended solely for the purpose of determining your qualifications for making an application for permanent residence in Canada.
The information submitted will only be viewed by Ms. Andréa de Rocquigny and will not be shared with any other person, organization or company.
In order to receive a response from our office in regards to your evaluation, please ensure that you have included your correct email address.
1.) E-mail address :
2.) Family Name :
First Name :
Middle Name :
3.) Sex : Male Female
4.) Date Of Birth : Day Month Year
5.)
Place Of Birth : City/Province/Country
6.) Citizen Of :
7.) Resident of :
8.) If not a citizen of country currently residing,what is your status in that country?
Work Permit :
Study Permit :
Others :
9.) Present address :
10.) Native language :
11.) Fluency in English : 0 1 2 3 4 5
(0 being none, 5 being fluent)
12.) Fluency in French : 0 1 2 3 4 5
(0 being none, 5 being fluent)
13.) MaritalStatus:
Married
Single
Divorced/Separated
14.) Number of years of full time employment : years
15.) Current occupation :
16.) Total years of education
Primary :
Secondary (High School) :
University/College :
Technical College :
17.) Your highest level of COMPLETED education
Less than secondary :
Secondary :
Technical trade certificate :
Non-university certificate or diploma
Some university, but no degree :
Bachelor degree :
Master degree :
Doctorate :
17a) What is the FULL name of the diploma of your highest COMPLETED level of education?
17b) What is the FULL name of the institution from which you obtained this diploma?
18.) In what language did youstudy in secondary school?
English :
French :
Others :
19.) In what language did you study in university/college/technical college?
English :
French :
Others :
If not married, please skip to question 26.
20.) If married, what is your spouse’s name?
Family Name :
First Name :
Middle Name :
20a) Your Spouse's Date Of Birth : Day Month Year
21.) What is your spouse occupation?
21a) How many years of full time work experience does he/she have?
22.) Total years of your spouse's education
Primary :
Secondary (High School) :
University/College :
Technical College :
23.) Spouse’s highest level of COMPLETED education
Secondary or less :
Formal trade :
Non-university certificate or diploma :
Some university, but no degree :
Bachelor degree :
Master degree :
Doctorate :
23a) What is the full name of the diploma of your spouse's highest COMPLETED level of education?
24.) In what language did your spouse study in secondary school?
English :
French :
Others :
25.) In what language did your spouse study in university/college/technical college?
English :
French :
Others :
26.) Do you have any children? Yes No
27.) If you answered “yes” to question #26,please indicate how many children and their age
Number of children :
Age for child 1 : years
Age for child 2 : years
Age for child 3 : years
Age for child 4 : years
Age for child 5 : years
Age for child 6 : years
28.) Destination in Canada: : city/province
29.) Do you have any relatives in Canada ? Yes No
30.) If you answered “yes” to question #29,then whom is your closest relative in Canada?
Brother/sister :
Mother/father :
Aunt/uncle :
Child :
Other :
31.) If you answered “yes” to question #29,what city/province is your relative located?
Please specify:
32.) Have you ever visited Canada? Yes No
33.) If you answered “yes” toquestion #32, please state:
Province :
Status : visitor student work
Length of time in Canada : Years Months
34.) How much money will you bring with you when you arrive in Canada ?
Please Specify :
35.) Do you have an offer of employment in Canada? Yes No
36.) If you answered “yes” to question #35,please describe and give name of employer.
Name of employer :
Description :
37.) Have you or has any one of your dependent ever
Been convicted of or currently charged with a crime or offence in any country? Yes No
Been detained or incarcerated? Yes No
Been refused refugee status in, or an immigrant or visitor visa to, Canada or any other country? Yes No
Been refused admission to, or ordered to leave, Canada or any other country? Yes No
38.) If you answered “yes” to any of the questions in #37, please provide details :
39.) Any other information that will help in the assessment of your qualifications :
40.) I certify that the information submitted is complete, accurate and factual. Yes No
