DATA CAPTURE FORM
PERSONAL INFORMATION
Full Name (as shown in your passport)
Last Name
Given Name and Middle Name (if applicable)
Have you used any other names?
Please Select
Yes
No
(e.g. Nickname,maiden name, alias, etc.)
If yes, provide the other used name:
Last Name
Given Name and Middle Name (if applicable)
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Place of Birth
Country
Gender
Please Select
Male
Female
Height
Eye Color
Citizenship
Current Country of Residence
From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
During the past five years, have you lived in the country other than your country of citizenship or current country of residence?
Please Select
Yes
No
If yes, provide the following information:
From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Current marital status
Please Select
Single
Married
Common-law
Widowed
Others
If you're married or in a common-law relationship, provide the date of marriage or start of common-law relationship
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Full name of Spouse
First Name
Last Name
Have you previously been married or in a common-law relationship?
Please Select
Yes
No
If yes, provide the name of your previous relationship
First Name
Last Name
Type of Relationship
Please Select
Married
Common-law
From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Passport Number
Country of Passport Issue
Issued date of Passport
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Expiry date of Passport
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
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CONTACT INFORMATION
Current mailing address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Residential address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main Contact Number
Please enter a valid phone number include country and area code.
Format: (000) 000-0000.
Email Address
example@example.com
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DETAILS OF VISIT TO CANADA
Purpose of Visit
From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Start Date of Stay
To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
End Date of Stay
Name, address and relationship of any person(s)or institution(s) you will visit:
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EDUCATION
Have you had any post secondary education/college?
Please Select
Yes
No
If yes, give full details of your highest level of post secondary education
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EMPLOYMENT
Give details of your employment for the past 10years, including if you held any government positions (such as civil servant, judge, mayor, police officer, Member of Parliament, hospital administrator, employee of a security organization). Do not leave gaps. If retired, notworking or studying, please indicate. If you are retired, please provide the 10years before your retirement. Use additional sheet of paper if necessary.
Employment 1
Employment 2
Employment 3
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ACTIVITIES FOR THE LAST 10 YEARS
State if working, unemployed, studying, etc. for the last 10 years or after 18 years old
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BACKGROUND INFORMATION
You must complete this section if you are 18years of age or older.
Within the past two years, have your or a family member had tuberculosis of the lungs or been in close contact with a person with tuberculosis?
If you answer Yes, provide details.
Do you have any physical or mental disorder that would require social and/or health services, other than medication, during a stay in Canada?
If you answer Yes, provide details.
Have you been remained beyond the validity of your status, attended school without authorization or worked without authorization in Canada?
If you answer Yes, provide details.
Have you been refused any kind of visa, admission, or ordered to leave Canada or any other country?
If you answer Yes, provide details.
Have you previously applied to enter or remain in Canada?
If you answer Yes, provide details.
Have you ever been committed, been arrested for, been charged with or convicted of any criminal offense in any country?
If you answer Yes, provide details.
Did you serve any military, militia, or civil defense unit or serve in a security organization or police force (including non obligatory national service, reserve or volunteer units)
If you answer Yes, provide details.
Are you, or have ever been a member or associated with any political party, or other group or organization which has engaged in or advocated violence as a means to achieving a political or religious objective, or which has been associated with criminal activity at any time?
If you answer Yes, provide details.
Have you ever witnessed or participated in the ill treatment of prisoners or civilians, looting or desecration of religious building?
If you answer Yes, provide details.
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FAMILY INFORMATION
Complete ALL names in English and in your native language (for example, Arabic, Cyrillic, Chinese, Chinese Commercial/telegraphic code, Korean, or Japanese characters). Include ALL family members even they are not accompanying you.
Spouse / Common-law partner (put N/A if not applicable)
Mother
Father
Children Information
Use additional sheet of paper if necessary
Child 1 relationship to applicant (put N/A if not applicable)
Please Select
Son
Daughter
Step-son
Step-daughter
N/A
Child 1 Information
Child 2 relationship to applicant (put N/A if not applicable)
Please Select
Son
Daughter
Step-son
Step-daughter
N/A
Child 2 Information
Siblings Information
Use additional sheet of paper if necessary
Sibling 1 relationship to applicant (put N/A if not applicable)
Please Select
Brother
Sister
Half-brother
Half-sister
N/A
Sibling 1 Information
Sibling 2 relationship to applicant (put N/A if not applicable)
Please Select
Brother
Sister
Half-brother
Half-sister
N/A
Sibling 2 Information
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UPLOAD YOUR UPDATED RESUME HERE
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