ASSESSMENT FORM

(For visitors and vactioners)

If you are married, please have your spouse complete this form also.

PERSONAL INFORMATION

First name :

Last name :

Sex :

Date of Birth (dd/mm/yyy) :

Marital status :

Citizenship :

Name of spouse:

Ocupation of Spouse :

No. children under 18 :

Relative in Canada:
(Relatives are citizens of
Canada)

	YES	NO		YES	NO
Parents			Uncle
Brother			Nephews
Sister			Nieces
Aunt			Grandparents

Address :

Phone number:

Fax number :

E-Mail:

BUSINESS INFORMATION (REQUIRED BY THOSE WHO ARE SELF EMPLOYED)

Name of Business:
Type of Business :
Registered or Inc. :
Gross Income per year:
Total value of Inventory :
Number of employees :
How much money do you have to invest:
Business Plan :	(Please let me know what business you propose to do in Canada and provide me with a BUSINESS PLAN. If the space provided herein is insufficient you may use additional paper to do so.)

EMPLOYMENT INFORMATION (REQUIRED BY THOSE WHO ARE NOT ESLF EMPLOYED)

Name of Employer:
Type of Business :
Your Job Title. :
Gross Income per year:
No. of years with Employer :
Letter approving leave? :
How much money do you have to travel with:
Purpose of your Visit :	(Please state in detail the purpose of your visit propose to do in Canada

FINANCIAL INFORMATION (US$)

Real Estate :
Bank Accounts:
Fixed Deposits :
Others :
Debts :
Net worth :

Please include any additional information that may be important :

EDUCATION

HIGHEST LEVEL OF EDUCATION :
CERTIFICATES :		list type of degree/diploma/certificate.
YEARS TO COMPLETE :	YEARS
OTHER EDUCATION:		list type of degree/diploma/certificate.
YEARS TO COMPLETE :	YEARS

WORK HISTORY

Choose job title from the occupational list

JOB TITLE:
DESCRIBE DUTIES AT WORK :
YEARS OF EXPERIENCE :
PREVIOUS OCCUPATION :
YOUR DUTIES :
YEARS OF EXPERIENCE :
SPOUSES OCCUPATION :

LANGUAGE SKILLS

ENGLISH
SPEAK :	FLUENT WELL SOME NONE
READ :	FLUENT WELL SOME NONE
WRITE :	FLUENT WELL SOME NONE
FRENCH
SPEAK :	FLUENT WELL SOME NONE
READ :	FLUENT WELL SOME NONE
WRITE :	FLUENT WELL SOME NONE

OTHER INFORMATION

Have you been convicted or currently charged with a crime in any country?	YES NO
Previously sought refugee status or applied for an immigrant or visitor visa in Canada?	YES NO
Been refused refugee status/immigrant/visitor visa to Canada or any other country?	YES NO
Been refused admission to, or ordered to leave Canada or any other country?	YES NO
Been detained or incarcerated?	YES NO
Do you or your spouse or children have any serious disease or physical or mental disorder?	YES NO
If you answered "YES" to any of the above, provide further details :
Please include any additional information that may be important :