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Client Self-Assessment Form

If you are married, kindly have your spouse complete a separate assessment form.

Personal information

Family Name:

Given Names:

Date of Birth:

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Sex:

Citizenship:

Country of Residence:

Marital Status:





Name of Spouse: (optional)

Do you have any children?

If you do have children, how many and what are their ages?

Ability in English:

Ability in French:

Have you ever taken a language test?

If you have taken a language test please provide details:

Full Mailing Address (include Country)

Email Address

Primary Phone Number

Secondary Phone Number (optional)

Work information

Current Occupation:

What are you Job Duties and Description:

Start Date of Current Job:

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Previous occupation in the last 10 years (optional):

Start and End Dates of Previous Job:

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Have you ever worked in Canada?

If yes provide details:

Do you have a job offer in Canada?

If yes provide details:

Education information

Years of education:

Highest Level of Education Achieved:






Post Secondary Institution(s)

Please provide the type of degree/diploma, the name/place of the instition and the years you studied there.

Other Education Achieved:

Do you have a Diploma or a Certificate?

If yes provide details:

Have You Ever Studied in Canada?

If yes provide details:

General information

Funds Available to Transfer to Canada in US Dollars:

Do you have any Relatives Living in Canada?

If yes provide details:

Have you or any dependant ever had any serious disease or mental disorder

If yes provide details:

Have you or any dependant ever had a criminal charge or conviction?

If yes provide details:

Have you or any dependent previously applied for an Immigration Visa or Visitor Visa to Canada?

If yes provide details:

Have you or any dependent ever been refused a visa, admission, or ordered to leave Canada or any country?

If yes provide details:

Please provide our office with any additional information you believe we should know about in the box below:

How did you find us?

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If other please provide details:

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