Personal Information
Full Name*
email*
Mailing Address
City
State / Province:
Zip / Postal Code:
Country:		Select one Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua & Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia & Herzegovina Botswana Bouvet Island Brazil Brit. Indian Ocean Terr Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Rep. Chad Chile China Christmas Island Cocos (Keeling) Is Colombia Comoros Congo Cook Islands Costa Rica Côte d'Ivoire Croatia (Hrvatska) Cuba Cyprus Czech Republic Congo (DRC) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Islands Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea GuineaBissau Guyana Haiti Heard & McDonald Is Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau SAR Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Is Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda St. Kitts & Nevis St. Lucia St Vincent & Grenadines Samoa San Marino São Tomé & Príncipe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa S Georgia & Sandwich Is Spain Sri Lanka St. Helena St. Pierre & Miquelon Sudan Suriname Svalbard & Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Turks and Caicos Is Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States US Minor Outlying Is Uruguay Uzbekistan Vanuatu Vatican City Venezuela Viet Nam Virgin Islands (British) Virgin Islands Wallis and Futuna Yemen Yugoslavia Zambia Zimbabwe
Telephone Home:
Telephone Work:
Gender		Select one Male Female
Marital Status:		Select one Never married Engaged Common-Law Married Separated Divorced Widowed
Birth date:		Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Dependants
How many children do you have who are:
0 - 10 Years old 11 - 18 Years old 19 - 22 Years old 23 and over Select one 0 1 2 3 4 5 6 7 8 Select one 0 1 2 3 4 5 6 7 8 Select one 0 1 2 3 4 5 6 7 8 Select one 0 1 2 3 4 5 6 7 8
Do you have any relatives in Canada?		Yes	No
If yes,	Relationship to you? Select one Wife Husband Fiance(e) Common-Law Partner Daughter Son Mother Father Sister Brother Grandmother Grandfather Aunt Uncle Cousin Nephew Neice Other	Location in Canada? Select one Ontario Quebec British Columbia Alberta Manitoba New Brunswick Nova Scotia Newfoundland Saskatchewan Prince Edward Island Yukon Nunavut North West Territories
Language Proficiency
Fluent Moderate Basic None English   Speak   Read   Write   Listen French   Speak   Read   Write   Listen
Education
Indicate the number of years of full-time studies or equivalent successfully completed:		10 or less 11 12 13 14 15 16 17 18 19 20
Indicate your highest level of education:
Did not complete high school   High school (Diploma equivalent to 11 years of full-time study)     Post-secondary diploma / certificate for 1 year of full-time studies or equivalent (Diploma equivalent to 12 years of full-time study)   Post-secondary diploma / certificate for 2 years of full-time studies or equivalent (Diploma equivalent to 13 years of full-time study)   Post-secondary diploma / certificate for 3 years of full-time studies or equivalent (Diploma equivalent to 14 years of full-time study)     University degree at bachelor level for 1 year of full-time studies or equivalent (Diploma equivalent to 14 years of full-time study)   University degree at bachelor level for 2 years of full-time studies or equivalent (Diploma equivalent to 15 years of full-time study)   University degree at bachelor level for 3 years of full-time studies or equivalent (Diploma equivalent to 16 years of full-time study)   University degree at bachelor level for 4 years of full-time studies or equivalent (Diploma equivalent to 17 years of full-time study)   Doctoral or Master's level     Type(s) of diploma(s) issued, and year (e.g. B.Sc. in Psychology, 1998) Name of institution, and year: (e.g. Yale University, 1998)
Work Experience
What is your occupation? How many years of full-time work experience do you have in this occupation? Select one 0 - 6 months 6 - 12 months 1 year 2 years 3 years 4 years 5 years 6 years If you have a second occupation (trade or profession), what is it? How many years of full-time work experience do you have in this other occupation? Select one 0 - 6 months 6 - 12 months 1 year 2 years 3 years 4 years 5 years 6 years Have you worked in Canada? Yes No If yes, Location in Canada? Select one Ontario Quebec British Columbia Alberta Manitoba New Brunswick Nova Scotia Newfoundland Saskatchewan Prince Edward Island Yukon Nunavut North West Territories How long? Select one 0 - 6 months 6 - 12 months 1 year 2 years 3 years 4 years 5 years 6 years
Business Experience
Do you own a business, manage a business or are you self-employed?		Yes
No
If yes, provide details of your business activities here:
Funds
Total Assets
Transferable Money
Quebec
To assess your qualifications under the Quebec program, please answer the following questions:
Do you have any relatives in the province of Quebec?		Yes No
If yes, Relationship to you? Select one Wife Husband Fiance(e) Common-Law Partner Daughter Son Mother Father Sister Brother Grandmother Grandfather Aunt Uncle Cousin Nephew Neice Other
Do you have friends in the province of Quebec?		Yes No
Have you ever visited the province of Quebec?		Yes No
If yes, Purpose of visit? Select one Visit - 2 weeks or less Visit - 2 weeks to 3 months Visit - 3 months or more Studies - 3 months (one semester) Studies - 6 months or more Work - 3 months Work - 6 months or more Internship - 3 months Internship - 6 months or more
Spouse or Partner
if you are married, living in a common-law relationship, or about to be married provide answers to the following questions:
Spouse's Birth date:
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Number of years of full-time education (starting at primary): Select one 0 - 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years
Does your spouse have a high school certificate? Yes No
Highest diploma / certificate earned: Select one Secondary / High School Technical / Vocational School College - Bachelors University - Bachelors University-Masters University-Ph.D. Other
Spouse's occupation:
Number of years of full-time work experience: Select one 0 - 6 months 6 - 12 months 1 year 2 years 3 years 4 years 5 years 6 years
Fluent Moderate Basic None English   Speak   Read   Write   Listen French   Speak   Read   Write   Listen
Other Infomation
Please tell us who or how you were referred to our website:
Please tell us what is motivating your interest in immigration or provide any other details you believe we should consider in assessing your questionnaire:

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