CLIENT ASSESSMENT FORM

Last Name: / / First Name: / Middle Name:
Mailing Address: / House #: / Street:
City: / State/Province: / Country:
Postal Code:
Telephone: / Home: / Business:
Fax: / Email:

Personal Information

Date of Birth: / Day: / Month: / Year: / Sex: / q  Male / q  Female
Place of Birth: / City: / State: / Country:
Citizenship:
Marital Status: / q  Never Married / q  Engaged / q  Married
q  Widowed / q  Separated / q  Divorced
q  Living with same sex-partner for more than a year
q  Living with common-law partner for more than one year
PERSONAL DETAILS OF YOUR SPOUSE
Spouse Info: / If you are married or engaged please provide details of spouse
Full Name:
Date of Birth: / Day: / Month: / Year:
Citizenship:
Occupation:
Experience:
Date of Marriage: / Day: / Month: / Year: / Place:
EDUCATION
Highest Completed / University Degree / Non University Diploma
q  Primary School / q  1 year University credential / q  One year
q  High School / q  2 year University credential / q  Two year
q  3 year University credential / q  Three year
q  2 Bachelor’s degrees
q  Masters
q  Phd
Years of School: / How many years of school have you completed? / ______Total Years
PERSONAL DETAILS OF YOUR FAMILY
Family Info:
Children: / Full Name / Date of Birth
Indicate Relatives in Canada if any: / Name / Relationship / Address
EDUCATION INFO
Period / Name & Address of Institutions / Courses / Degree / Diploma / Certificate Issued
From / To
Total Years of school successfully completed / ______Years
EMPLOYMENT
Intended Occupation In Canada
WORK HISTORY
Date / Name & Address of Employer / City & Country / Job Designation
From / To
Present Occupation / Current Occupation: / Current Monthly Earnings:
Job Description: / Please attach a separate Sheet giving a detailed description of the job responsibilities performed by you on a day to day basis:
Total Work Experience: / How many Years of work experience do you have in the last 10 years?
q  0 / q  1 / q  2 / q  3 / q  4 & Up
LANGUAGE ABILITY
Please indicate your ability to communicate in English and French by checking the appropriate column

English

/ Fluently / Well / With Difficulty / Not at all
Speak / q  / q  / q  / q 
Read / q  / q  / q  / q 
Write / q  / q  / q  / q 

French

/ Fluently / Well / With Difficulty / Not at all
Speak / q  / q  / q  / q 
Read / q  / q  / q  / q 
Write / q  / q  / q  / q 

Language Test

/ Have you or could you pass a formal English/French Language Test?
English / French
q  Yes / q  No / q  Yes / q  No
Transferable Funds / Assets: / Cash (in CDN$) / Property
OTHER DETAILS
Yes / No
q  / q  / Do you hold a work permit for Canada?
q  / q  / Do you have a job offer or potential job offer from a Canadian employer?
q  / q  / Have you or your spouse, common law partner or same sex partner ever worked in Canada for one full year?
q  / q  / Have you or your spouse, common law partner or same sex partner ever studied in Canada for more than two years?
q  / q  / Do you or your spouse, common law partner or same sex partner have a valid offer of employment in Canada upon your arrival?
q  / q  / Do you have a spouse, common law partner or same sex partner who is a Canadian Citizen or Permanent Resident?
q  / q  / Do you or your spouse, common law partner or same sex partner have any close family relationships in Canada?
q  / q  / Will you be able to bring with you more than CDN$25000 when you immigrate?

BUSINESS APPLICANTS ONLY

Yes / No
q  / q  / Are you willing to invest or start a business in Canada?
q  / q  / Have you in the last 5 years ever made a trip to Canada to explore business opportunities?
q  / q  / Do you have a personal net worth of at least $300,000 CDN?
q  / q  / Have you ever managed more than 5 people?
q  / q  /

If yes, describe briefly?

q  / q  / Have you ever been self-employed as a musician or artist, or in other cultural activities?
q  / q  / Have you ever owned or managed a farm?
q  / q 
Company Details: / Complete this section if you have owned a company in the last 5 years? If yes, email a complete business profile of your company to .
q  / q  / Have you ever owned and operated your own business?
q  / ___% / What percentage of the company did you own?
q  __ / People / How many people have you employed?
q  / q  / Has your company had gross sales of more than $500,000 CDN per year in at least 2 of the last 5 years?
q  / q  / Has your company had net income of more than $50,000 CDN per year in at least 2 of the last 5 years?
q  / q  / Has your company had net equity of more than $125,000 CDN per year in at least 2 of the last 5 years?
Turnover & Net Profit over the last 3 years / Year / Turnover / Net Profit
Net Worth in Canadian $ / Bank / Property / Assets / Other / Total
If others give details here:
The Value of all your assets
Funds available to be transferred to Canada
ADDITIONAL INFO
Visit Abroad / Have you ever visited abroad? If yes which countries?
q  / q  / q  / q  N/A
For which countries do you have a valid visitor’s visa?
q  / q  / q  / q  N/A
Do you have a work visa for any country?
q  / q  / q  / q  N/A
Canada
Have you ever visited Canada? / q  Yes / q  No
Where: / When: / Purpose:
Have you ever studied in Canada? If yes, give details:
Institution: / Course: / Date:
Why Canada? /

Please briefly explain your interest in immigrating to Canada?

Any other information you think will be relevant to our assessment of your application?
How did you hear about us?
q  Referral / q  Friend / q  Seminar
q  Newspaper / q  Internet / q  Other ______
I declare that information given in this application is truthful, complete and correct.
Date: Signature:
Information provided to our firm is strictly Private & Confidential.