Confidential Assessment Questionnaire

Confidential Assessment Questionnaire

Please use this form to provide us with the information necessary to begin evaluation of your case. We will be best able to help you if you are sure to provide complete and accurate information. Any information you supply to James Norris Ltd. will be treated as strictly confidential, and will never be revealed without your explicit permission.

Select what kind of immigration application you would like to make:
Skilled Worker Applicant Business Applicant Family Class

Email Address:

Surname:
First Name: Middle Name:

Date of Birth Year: Month: Day:
Height (in cm):
Eye Colour:
Place of Birth City or Town: State or Province: Country:
If you were born in different country, please specify:
Citizenship:
Passport Number:
Passport Expiry:

Permanent Address:

My mailing address is:
the same as my permanent address.
different from the permanent address, and is:

My telphone number is: -

Martial status
Never married Married Widowed Separated Divorced Common law

Personal Details of All My Dependents
Spouse / Common law partner
Name:
Date of Marriage / Date Common law Relationship Started:
Date of Birth:
Height (in cm):
Eye Colour:
Place of Birth: Citizenship: Passport Number:
Passport Expiry:
To accompany me to canada Yes No

Children
Name:
Date of Birth:
Height (in cm):
Eye Colour:
Place of Birth:
Citizenship: Passport Number:
Passport Expiry:
Relationship:
To accompany me to canada Yes No

Name:
Date of Birth:
Height (in cm):
Eye Colour:
Place of Birth:
Citizenship: Passport Number:
Passport Expiry:
Relationship:
To accompany me to canada Yes No

Name:
Date of Birth:
Height (in cm):
Eye Colour:
Place of Birth:
Citizenship: Passport Number:
Passport Expiry:
Relationship:
To accompany me to canada Yes No

Name:
Date of Birth:
Height (in cm):
Eye Colour:
Place of Birth:
Citizenship: Passport Number:
Passport Expiry:
Relationship:
To accompany me to canada Yes No

Name:
Date of Birth:
Height (in cm):
Eye Colour:
Place of Birth:
Citizenship: Passport Number:
Passport Expiry:
Relationship:
To accompany me to canada Yes No

My Ability in English
Mother tongue is:

Speak:	fluently well with difficulty not at all
Read:	fluently well with difficulty not at all
Write:	fluently well with difficulty not at all

My Ability in French

Speak:	fluently well with difficulty not at all
Read:	fluently well with difficulty not at all
Write:	fluently well with difficulty not at all

My Education
Years of elementary school: Years of secondary/highschool: Years of university / college: Years of formal apprenticeship / training:

My Secondary & Post Secondary Education:
tr>

Dates		Name of Institution (Including apprenticeship training)	City and Country	Type of Certificate or Diploma issued
From	To

My Employment Details
My present occupation is:
My intended occupation in Canada is:

My work history (most recent first):
Dates (from to) Name of employer:
City / Country: Occupation:
Description:

Dates (from to) Name of Employer:
City / Country: Occupation:
Description:

Dates (from to) Name of Employer:
City / Country: Occupation:
Description:

Dates (from to) Name of Employer:
City / Country: Occupation:
Description:

Dates (from to) Name of employer:
City / Country: Occupation:
Description:

I have a job offer in Canada Yes No
Company Name:
Company Address: (Leave blank if answered "No" above)

The following person, employer or organization in Canada has offered to assist me after my arrival
The relationship of this person to me:
My Destination in Canada:

My Financial Information
I have the following assets\money:
Property:

Fixed Deposits:

Monthly pension:
Other:

I have the following debts:
Debts: Amount:
Debts: Amount:

Other Information
Since my 18th Birthday I have lived at the following addresses:

Dates		Street and Number	City and State/Province	Country
From	To

Since my 18th birthday I have been (or still am) a member of, or associated with, the following political, social, youth, student, or vocational organizations (including trade union and professional associations), include any military service (show rank, unit and location of service in last column).

Dates		Name and Address of Organization	Type of Organization	Position held (if any)
From	To

My Parents
Father's full name: Date of Birth:
City, town,country of your father's birth:
Present Address in full, if deceased, give date):

Mother's full name before marriage: Date of Birth:
City, town,country of your mother's birth:
Present Address in full (if deceased, give date):

Have you or any one of your dependents ever

A. Had any serious disease of physical or mental disorder? Yes No

B. Been convicted of or currently charged with any crime or offence in any country? Yes No

C.Applied previously for an immigrant or visitor visa to Canada? Yes No

D. Been refused an immigrant or visitor visa to Canada or any other country? Yes No

E. Been refused admission to, or ordered to leave Canada or any other country? Yes No

F. In period of either peace or war, have you ever been involved in the commission of a war crime or crime against humanity, such as: willful killing, torture, attacks upon, enslavement, starvation or other inhumane acts committed against civilians or prisoners of war, or deportation of civilians? Yes No

Please explain any "yes" answers:

I prefer to be contacted by:
E-mail; The E-mail address is
Mail
Fax; The Fax Number is

Thank you for your interest in James Norris Ltd's Canadian Immigration consultation service. We will begin evaluation of your case immediately upon receipt of the information. No fee is necessary for this service.