Canadian Immigration Assessment Form

PRINCIPLE APPLICANT

Name*

First & Middle NameLast Name

Sex*

MaleFemale

Date of Birth*

Date

Place of Birth (City, Province, Country)*

Eye Colour*

Height*

Phone Number*

Area CodePhone Number

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Country, Postal / Zip Code

Martial Status*

Country Citizenship*

UCI number (if applicable)

Have you ever been issued a removal order in Canada*

YesNo

Have you previously been married or in a common law relationship*

YesNo

If Yes, Name of previous spouse or partner

First NameLast Name

Type of Relationship

MarriageCommon-law

From Date to (date of separation/divorce) Date

Passport & National ID

Number

Country of Issue

Date of Issue

Date

Date of Expiry

Date

Are you a lawful permanent resident of the United States with a valid alien registration card (green card)*

YesNo

Other ID

ID Type

ID Number

Country of Issue

Date of Issue

Date

Date of Expiry

Date

Where do you intend to live in Canada (City/Town, Province)*

Background/Declaration

Your full name as you write it in your native language*

Other name used*

Current country of residence*

Status in current country of residence*

Have you, or, if you are the principal applicant, any of your family members listed ever

	Yes	No
been convicted of, or are you currently charged with, on trial for, or party to a crime or offence, or subject of any criminal proceedings in any country?
previously sought refugee status in Canada or applied for a Canadian immigrant or permanent resident visa or visitor or temporary resident visa?
been refused refugee status in, or an immigrant or permanent resident visa or visitor or temporary resident visa to, Canada or any other country, or have been refused a Certificat de sélection du Québec (CSQ) to Quebec?
been refused admission to, or ordered to leave, Canada or any other country?
been involved in an act of genocide, a war crime or in the commission of a crime against humanity?
used, planned or advocated the use of armed struggle or violence to reach political, religious or social objectives?
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?
been a member of an organization that is or was engaged in an activity that is part of a pattern of criminal activity?
been detained or put in jail?
had any serious disease or physical or mental disorder?

If your answer to any of these questions is YES, provide details

Actual score in IELTS or CELPIP, if applicable:

	IELTS/CELPIP
Listening:
Reading:
Writing:
Speaking:

Actual score Test d'Evaluation de Français (TEF), if applicable:

	TEF
Listening:
Reading:
Writing:
Speaking:

ADDRESS HISTORY

Address History since age of 18.*

	From (YYYY-MM-DD)	To (YYYY-MM-DD)	Apt, Street no. and street name	City/Town/Province	Country
#1
#2
#3
#4
#5

EDUCATION AND EMPLOYMENT HISTORY

Indicate number of years of school successfully completed.*

	Elementary/Primary school	Secondary/High school	University/College	Trade school/other post secondary school
Type number

Secondary and Post-Secondary Education.*

	Institution/School Name	Start Date (MM-YYYY)	End Date (MM-YYYY)	City	Country	Type of Certificate or Degree Issued	Field of Study
#1
#2
#3
#4
#5

Current occupation*

Employment history since age of 18.*

	Start Date (MM-YYYY)	End Date (MM-YYYY)	Name of Employer	City	Country	Job Title & Job Duties
#1
#2
#3
#4

PERSONAL HISTORY

Give details of what you have been doing during since age 18 or the last ten years, whichever period is longer, starting with the most recent information. Include jobs held, periods of unemployment, periods of study and any other use of time, such as time spent traveling in search of a country of refuge, stays in hospitals, prisons or other places of confinement, and periods spent at home as a homemaker. You must NOT leave gaps.*

	From MM/YY	To MM/YY	Activities	City, province & country	Name of company, employer, school, facility, as applicable
#1
#2
#3
#4

MEMBERSHIP OR ASSOCIATION WITH ORGANIZATIONS

What organizations have you supported, been a member of or been associated with? Include any political, social, youth or student organization, trade unions and professional associations. Do not use abbreviations. Indicate the city and country where you were a member.

	From MM/YY	To MM/YY	Name of organization	Type of organization	Activities or positions held within organization	City, province, country
#1
#2
#3
#4

GOVERNMENT POSITIONS

List any government positions (such as civil servant, judge, police officer) you have held. Do not use abbreviations.

	From MM/YY	To MM/YY	Country and level of jurisdiction (e.g. national, regional, municipal)	Department/Branch	Activities/Position held
#1
#2
#3

MILITARY SERVICE

Provide below details of military service for each of the countries in whose armed forces you served.

	From MM/YY	To MM/YY	Name of Country	Branch of service, unit numbers and names of your commanding officers	Rank(s)	Dates and places of any active combat
#1
#2
#3

DIRECT FAMILY MEMBERS INFORMATION FOR SPOUSE OR COMMON-LAW PARTNER

How many family members do you have (including spouse, dependent children and their dependent children)

Name

First & Middle NameLast Name

Date of Birth

Date

Place of Birth (City, Province, Country)

Native Language

Will accompany you to Canada

YesNo

Eye Colour

Height

Phone Number

Area CodePhone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Country, Postal / Zip Code

Marital Status

Citizenship

UCI number (if applicable)

Level of Education

Total number of years of formal education

Have you ever been issued a removal order in Canada

YesNo

Passport Number

Date of Issue

Date of Expiry

Date

Actual score in IELTS or CELPIP:

	IELTS/CELPIP
Listening:
Reading:
Writing:
Speaking:

Actual score Test d'Evaluation de Français (TEF):

	TEF
Listening:
Reading:
Writing:
Speaking:

ADDRESS HISTORY

Address History for the past five years:

	From (YYYY-MM-DD)	To (YYYY-MM-DD)	Apt, Street no. and street name	City/Town/Province	Country
#1
#2
#3
#4
#5

EDUCATION AND EMPLOYMENT HISTORY

Secondary and Post-Secondary Education:

	Institution/School Name	Start Date (MM-YYYY)	End Date (MM-YYYY)	City	Country	Type of Certificate or Degree Issued	Field of Study
#1
#2
#3

PERSONAL HISTORY

Give details of what you have been doing during since age 18 or the last ten years, whichever period is longer, starting with the most recent information. Include jobs held, periods of unemployment, periods of study and any other use of time, such as time spent traveling in search of a country of refuge, stays in hospitals, prisons or other places of confinement, and periods spent at home as a homemaker. You must NOT leave gaps.

	From MM/YY	To MM/YY	Activities	City, province & country	Name of company, employer, school, facility, as applicable
#1
#2
#3
#4

MEMBERSHIP OR ASSOCIATION WITH ORGANIZATIONS

What organizations have you supported, been a member of or been associated with? Include any political, social, youth or student organization, trade unions and professional associations. Do not use abbreviations. Indicate the city and country where you were a member.

	From MM/YY	To MM/YY	Name of organization	Type of organization	Activities or positions held within organization	City, province, country
#1
#2
#3
#4

GOVERNMENT POSITIONS

List any government positions (such as civil servant, judge, police officer) you have held. Do not use abbreviations.

	From MM/YY	To MM/YY	Country and level of jurisdiction (e.g. national, regional, municipal)	Department/Branch	Activities/Position held
#1
#2
#3

MILITARY SERVICE

Provide below details of military service for each of the countries in whose armed forces you served.

	From MM/YY	To MM/YY	Name of Country	Branch of service, unit numbers and names of your commanding officers	Rank(s)	Dates and places of any active combat
#1
#2
#3

Employment:

	Start Date (MM-YYYY)	End Date (MM-YYYY)	Name of Employer	City	Country	Job Title & Job Duties
#1
#2
#3
#4

CHILDREN

Name

First & Middle NameLast Name

Date of Birth

Date

Place of Birth (City, Province, Country)

Native Language

Will accompany you to Canada

YesNo

Eye Colour

Height

Phone Number

Area CodePhone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Country, Postal / Zip Code

Marital Status

Citizenship

Level of Education

Total number of years of formal education

Have you ever been issued a removal order in Canada

YesNo

Passport Number

Date of Issue

Date of Expiry

Date

Name

First & Middle NameLast Name

Date of Birth

Date

Place of Birth (City, Province, Country)

Native Language

Will accompany you to Canada

YesNo

Eye Colour

Height

Phone Number

Area CodePhone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Country, Postal / Zip Code

Marital Status

Citizenship

Level of Education

Total number of years of formal education

Have you ever been issued a removal order in Canada

YesNo

Passport Number

Date of Issue

Date of Expiry

Date

Name

First & Middle NameLast Name

Date of Birth

Date

Place of Birth (City, Province, Country)

Native Language

Will accompany you to Canada

YesNo

Eye Colour

Height

Phone Number

Area CodePhone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Country, Postal / Zip Code

Marital Status

Citizenship

Level of Education

Total number of years of formal education

Have you ever been issued a removal order in Canada

YesNo

Passport Number

Date of Issue

Date of Expiry

Date

ADDITIONAL FAMILY INFORMATION

Complete ALL names in English and in your native language (for example, Arabic, Chinese, Korean, Chinese character code, or Japanese characters)

	Name	Relationship	Date of Birth	Place of Birth	Marital Status	Present Address or date of death if applicable
#1
#2
#3
#4
#5

I certify that I do not have any spouse or common-law partner. Date

Signature

Children (include ALL sons and daughters, including ALL adopted and step-children, regardless of age or place of residence)

	Name	Relationship	Date of Birth	Place of Birth	Marital Status	Present Address or date of death if applicable
#1
#2
#3
#4
#5

I certify that I do not have any children, either natural or adopted. Date

Signature

Brothers and sisters (including half-and step-brothers and sisters)

	Name	Relationship	Date of Birth	Place of Birth	Marital Status	Present Address or date of death if applicable
#1
#2
#3
#4
#5

WORK EXPERIENCE IN CANADA

Do you have an offer of employment in Canada*

YesNo

If Yes, Employer's name

Type a question

Are you currently working in Canada under a work permit

YesNo

Upload Work Permit

DOCUMENT CHECKLIST

The following list is not exhaustive, but for the majority of applications, it includes most of the documents required to process an application

Identity and civil status documents

Birth, marriage, final divorce, annulment or separation certificates for you and your spouse or common-law partner;
Death certificate for former spouse if applicable;
Photocopy of citizenship certificate or permanent resident visa (formerly called “immigrant visa”) for any family members who are Canadian citizens or permanent residents of Canada

Children’s information (if applicable)

Children’s birth certificates (which name their parents);
Adoption papers for adopted dependent children;
Proof of custody for children under the age of 18 and proof that the children may be removed from the jurisdiction of the court;
If the children will not accompany you to Canada, proof that you have fulfilled any obligation stated in custody agreements;
Proof of continuous full-time studies of all dependent children aged 22 or over, including:

complete school records/transcripts since attaining age 22
letters from the schools indicating the number of hours of classes attended per day, and the number of days attended per week
proof of full financial support by parents since reaching age 22

Travel documents and passports

Passports or travel documents for you, your spouse or common-law partner and your dependent children. Include all the pages even the blank ones.

If you live in a country different from your nationality, include a photocopy of your visa for the country where you currently live. Note that all prospective immigrants must hold a valid regular passport; diplomatic, official, service or public affairs passports are not valid for immigration to Canada.

Proof of relationship in Canada (if applicable)

Proof of relationship to any close relative in Canada, such as birth, marriage or adoption certificates and proof of that person’s status in Canada; photocopy of the Record of Landing (IMM 1000) of your parent or proof of Canadian citizenship such as photocopy of pages of a Canadian passport or Canadian citizenship card.

Education/Training/Qualifications (For you and your spouse or common-law partner)

Post-secondary education documents: vocational or technical certificates or diplomas;
College or university documents: certification of completion and the graduation degree, diploma, or certificate issued by the college or university and the evaluation committee;
Transcripts: original transcripts of all degrees must be submitted in university-sealed envelopes;
Professional qualifications certificates: notarized professional qualification certificates should be submitted if available. (e.g.. Engineer, Computer Programmer, Accountant, Economist, Translator/Interpreter, Architect etc.)

Work Experience (For you and your spouse or common-law partner)

notarized employment contracts from your present and past employers, accompanied by an English or French translation;
Original and up-to-date letters of reference from your past and current employers.
Letters must be written on company letterhead and show the company’s full address, telephone and fax numbers, and be stamped with the company’s official seal.

Letters must include all of the following information:

the specific period of your employment with the company
the positions you have held during the period of employment and the time spent in each position
your main responsibilities in each position
your total annual salary plus benefits
the signature of your immediate supervisor or the personnel officer of the company
a business card of the person signing
If you cannot provide a reference from your current employer, provide a written explanation.

Proof of language proficiency

Test results from an approved language-testing organization
Original copy of test results if you are claiming proficiency in a language that is not your native language. Language test results must not be older than one year upon submission.

Arranged employment (if applicable)

If you are currently working in Canada under a work permit, provide a photocopy of the permit.

Non-accompanying family member declaration (if applicable)

If you have a spouse, common-law partner or dependent children and you do not intend to include them in your application for permanent residence, submit with your application a notarized statutory declaration stating your intention to proceed to Canada without your family members, and confirming that you understand that your family members must meet immigration requirements in their own right if they wish to join you in Canada.

Settlement of funds

Provide proof of unencumbered and readily transferable funds in a convertible currency available for settlement in Canada (for you and your family members):

Current bank certification letter; or
Evidence of savings balance; or
Fixed or time deposit statements.

Police Certificates and clearances

Original police certificates of good conduct or clearances, from each country/state/territory in which you and everyone in your family aged 18 years or over have lived for six months or longer since reaching the age of 18;
Submit original fingerprints directly to the authorities conducting the police checks.
Photo requirements

8 specified photos (with name and date of birth on the back for each applicant) for each member of your family and yourself.

Files Upload*