Please complete a separate questionaire for each person
over the age of 18 years.

Your Telephone Number:
Who Referred You:
Your Lastname:
First Name:
Email Address:
Mailing Address:
Sex: Male Female
Date of Birth:
Maritial Status:
Spouse's Full Name:

Children's Name, Age & Sex:

Education: Please list the names and dates of all schools, colleges and universities attended, and what degree, diploma or certificate was granted.

Languages: Indicate your ability to speak, read and write, and whether fluently, well, little or not at all:
Mother Tongue:

What is your destination in Canada?

Do you have a job offer? Yes No
If yes, give details:

Do you have relatives in Canada?

Yes No
If yes, what is the relationship?

Do any of your relatives own a business in Canada?

Yes No
If yes, please give full details:

Will your relatives assist you financially, if necessary?

Yes No

Have you or any family member ever had medical problems?

Yes No
If yes, give full details:

Do you or an immediate family member have a criminal record?

Yes No
If yes, give full details:

Have you or a family member ever been denied entry into any country?

Yes No
If yes, give full details:

How much money do you have in US dollars in:
Liquid Funds:
Real Estate:

What is your present income?

What are your total debts?

Work Experience: Provide as much detail as possible, including years of experience, job title and responsibilities.
Current occupation:
(Date commenced)
All previous occupations:
(How long in each)

Have you ever owned your own business?

Yes No
If yes, give details e.g. what percentage of the business, duties, etc.



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