Assessment Questionnaire

For your convenience, we’ve prepared a detailed questionnaire to collect important information about your background. It is very important to provide our office with a complete set of answers. This information is the foundation upon which we make an informed decision regarding the best possible route for you to be able to immigrate to Canada.

If you are a Canadian citizen and seeking our advice on how best to enter USA for business or pleasure purposes, then we ask that you please complete this questionnaire as well. The questions may be geared towards immigrating to Canada, but the Department of Homeland Security requires the same information concerning your background in terms of education and work experience.

Questionnaire

Step 1 of 15

First Name
Middle Name
Surname
Maiden Name
Other Name(s) you go by
Date of Birth (dd/mm/yyyy)
Town/City of Birth
Province/State of Birth
Country of Birth
Country of Citizenship
Address
Home Phone Number
Cell Phone Number
Work Phone Number
Fax Number
Email
Eye Color
Height
Native Language

Section 2 - Passport Information
Passport Number
Country of Issue
Issue Date (dd/mm/yyyy)
Expiry Date (dd/mm/yyyy)

Section 3 - Marital Status
Marital Status
Please check all that apply
Spouse/Partner Information (If Applicable):
First Name
Middle Name
Surname
Maiden Name
Sex
- Male
- Female
Date of Birth (dd/mm/yyyy)
Height
Weight
Eye Color
Citizenship
Country of Birth
Country of Residence
Other Countries with Resident Status
Marital Status
Languages Spoken (list all)
Highest Level of Education Completed
Current Occupation
Will accompany you to Canada?
- Yes
- No
Passport Information
Date of Expiry
Country of Issue
Identity Card Number

Previous Partner Information (If Applicable):
Full Legal Name
Date of Birth (dd/mm/yyyy)
Address

SECTION 4 - FAMILY BACKGROUND
Please list ALL family members. Indicate family members who are deceased, as well as date of death.
Parent Information
First Name
Middle Name
Surname
Maiden Name
Date of Birth (dd/ mm/yyyy)
City/Town of Birth
Country of Birth
Date of Death (dd/mm/yyyy) if applicable:
Occupation
Address

Sibling Information
First Name
Middle Name
Surname
Maiden Name
Sex
- Male
- Female
Date of Birth (dd/ mm/yyyy)
Town of Birth
Country of Birth
Marital Status
Current Occupation
Present Address

Children Information
Please include ALL of your children, whether they are dependent or not. Please include all children that you have custody of as well as any children who you do not have custody of. Be sure to indicate children of all partners. Add additional paper if necessary.
First Name
Middle Name
Surname
Sex
- Male
- Female
Height
Weight
Eye Color
Citizenship
Country of Birth
Country of Residence
Other Countries with Resident Status
Marital Status
Languages Spoken (list all)
Highest Level of Education Completed
Current Occupation
Will accompany you to Canada?
- Yes
- No
Passport Number
Date of Expiry
Country of Issue
Identity Card Number

SECTION 5 - EDUCATION HISTORY
Total years of formal education
Total years of elementary
Highest level achieved
- No secondary
- Secondary
- Trade/Apprenticeship
- College Certificate/Diploma
- Bachelor’s degree
- Master’s degree
- Doctorate/PhD
Please check highest level
School/Institution Information 1
Start Date (dd/mm/yyyy)
End Date (dd/mm/yyyy)
Name of School
City of School
Country of School
Major (if applicable)
Certificate/Diploma
Language of Instruction

SECTION 6 - EMPLOYMENT INFORMATION
Current Occupation
Name of Company
Supervisor’s Name
City/Country
Address
Monthly Income (in Canadian Dollars)

Employment History
List
From (dd/mm/yyyy) To (dd/mm/yyyy) Company/ Employer Position/Job Title City/ Country Address Contact Person (Include phone number) Full time or Part time? Monthly Income (in CDN dollars)

SECTION 7 – IMMIGRATION HISTORY TO ALL COUNTRIES OUTHER THAN YOUR ORIGINAL CITIZENSHIP
In how many countries are you and/or your family members considered citizens or permanent residents?
If you and/or your immediate family members are considered citizens or permanent residents in more than one country, please describe
Have you or any of your immediate family members EVER applies for ANY visa to ANY country in the world (e.g. visitor visa, study or work permit, immigrant in another country)
Have you or your immediate family members ever claimed refugee status or asylum in any country in the world?
If you answered yes above, please explain:
Have you or any of your immediate family members ever been refused ANY visa to ANY country in the world?
If you answered yes above, please explain:
Have you or your immediate family members ever been refused admission into Canada (e.g. not being granted permission to enter Canada from the USA or by airplane or ship from any other country)?
If you answered yes above, please explain

SECTION 8 – ADDRESSES
Please list all addresses that you have resided at since your 18th birthday OR in the past 10 years, whichever is more recent. Do not leave any gaps. Please list all addresses in reverse chronological order (most recent to most distant).
List
From (dd/ mm/yyyy) To (dd/mm/ yyyy) Street Address Town/City/ Province Postal/Zip Code Country
SECTION 9 – TRAVEL HISTORY
Please list all travel history since your 18th birthday, or from the past 10 years, whichever is more recent.
List
From (dd/ mm/yyyy) To (dd/mm/ yyyy) Country Location Purpose of Travel

SECTION 10 – ACTIVITY INFORMATION
Include all activities that you have done since your 18th birthday. DO NOT LEAVE GAPS. Include all trips, holidays, and whether employed or unemployed. Give exact dates and make sure not to leave any gaps in between the dates. Please fill in al addresses where you lived, stayed or worked – whichever is applicable. Add paper if necessary.
List
From (dd/mm/yyyy) – To (dd/mm/yyyy) Activity Position/Title City/Country Status in Country Name of School/ Company/Employer/ Facility
SECTION 11 – MEMBERSHIP INFORMATION
Add paper as necessary
Membership Information
Start Date (dd/mm/ yyyy) End Date (dd/mm/ yyyy) Name of Group City of Group Country of Group Position Held

SECTION 12 – GOVERNMENT/MILITARY INFORMATION
Please note all government and military positions held (include active combat and all levels of government).
List
Start Date (dd/mm/ yyyy) End Date (dd/mm/ yyyy) Name of Branch City of Branch Country of Branch Position Held Duties in Combat
SECTION 13 – HEALTH
Have you or any of your family members ever been diagnosed with or exposed to a serious illness (e.g. tuberculosis, diabetes, mental illness, multiple sclerosis)?
If you answered YES, please describe the illness & circumstances:

SECTION 14 – CRIMINAL HISTORY
Do you have a criminal record?
If you answered YES, please explain:
Have you ever been charted, arrested, detained or put in jail (e.g. DWI or DUI is a criminal offense in Canada)?
If you answered YES, please provide: - Charge: - Date of offense: - Date of conviction: - Punishment imposed: - Was any probation granted?:
Do you have a criminal record in more than one country?
If you answered YES, please list country/countries and explain
Have you ever been involved in a war crime, act of genocide, or act of terrorism?
If you answered YES, please explain in detail:
Do you have a close relative who is a permanent resident or citizen of Canada, an established resident of Manitoba band has been residing in Manitoba for at least one year?
If you answered YES, please provide: Full name, Address, Date of birth, Telephone number, Email, Relationship to you, Date he/she became a PR or citizen.
Do you have a friend in Manitoba who is a permanent resident or citizen of Canada, an established resident of Manitoba and is currently supporting the settlement of another individual through the MPNP or any other immigration program?
If you answered YES, please provide: Full name, Address, Date of birth, Telephone number, Email, Relationship to you, Date he/she became a PR or citizen.
Have you taken an English Test?
- Yes
- No
If you answered YES, please inform which test:
Test Scores
Listening Reading Writing Speaking

Get in touch with us

For more information or to speak to a professional about immigrating to the U.S., contact us at 204-817-0198 or fill out a request for information.

Assessment Questionnaire