QUESTIONNAIRE

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Section 1

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Main Applicant
Spouse
 
Last Name*: Last Name:
First Name*: First Name:
Middle Name: Middle Name:
Title*: Title:
Date of birth*:  YYYY/MM/DD Date of birth:  YYYY/MM/DD
Nationality*: Nationality:
Passport #:
Passport Expiry:  YYYY/MM/DD
Marital Status*:
Number of Children over 16*: Number of Children under 16*:
Address*:
 
City*:
Country*: Preferred contact method:
Phone (Home): Mobile (Home):
Fax (Home): Email (Home)*:
Phone (Office): Mobile (Office):
Fax (Office): Email (Office):
I apply for the following program*: As a*:
Closest MIS affiliate office*: Type of contract*:
Referred By:
 

Section 2 - Education

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Main Applicant
Spouse
 
English* English
Speak* High Moderate Basic None Speak High Moderate Basic None
Listen* High Moderate Basic None Listen High Moderate Basic None
Read* High Moderate Basic None Read High Moderate Basic None
Write* High Moderate Basic None Write High Moderate Basic None
 
French* French
Speak* High Moderate Basic None Speak High Moderate Basic None
Listen* High Moderate Basic None Listen High Moderate Basic None
Read* High Moderate Basic None Read High Moderate Basic None
Write* High Moderate Basic None Write High Moderate Basic None
 
Total years of formal education*: Total years of formal education:
Level of education*: Level of education:
 
University / College degree / Diploma obtained University / College degree / Diploma obtained
Ever studied in Canada*: Yes No Ever studied in Canada: Yes No
Details (How long? Where?) Details (How long? Where?)
 

Section 3 - Work experience

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Main Applicant
Spouse
 
Name of Employer / Business*: Name of Employer / Business :
Present Occupation / Business*: Present Occupation / Business:
No. of years of work / business experience*:    No. of years of work / business experience:
N.O.C #: N.O.C #:
Duties and Responsibilities / Detail of Business Duties and Responsibilities / Detail of Business
Ever worked in Canada*: Yes No Ever worked in Canada: Yes No
Details (How long? Where?) Details (How long? Where?)
Business you would prefer to establish in Canada: Business you would prefer to establish in Canada:
Type of Employment seeking in Canada: Type of Employment seeking in Canada:
 

Section 4 - Personal assets (Applicant and Spouse)

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Cash on Hand and in Banks: US $
Stocks and Bonds (market value): US $
Real Estate: US $
Equity in Business or Other Business Assets: US $
Termination Benefits (if applicable) US $
Other Assets: US $
Sub-total: US $
 
Less Any Outstanding Debts: US $
TOTAL ASSETS: Total Net Personal Worth* US $
 
Preferred destination in Canada:
 
 
Relatives in Canada*: Yes No Relationship / Where in Canada:
Have any member of the family:
Any medical problems?* Yes No
Ever been refused a visa for Canada?* Yes No
Been convicted of any crime or offence in any country?* Yes No
Ever applied for a visa for Canada?* Yes No

MARITIME IMMIGRATION SERVICES CANADA LTD. AND THEIR AFFILIATE OFFICES WILL RETAIN ALL INFORMATION AS PRIVATE AND CONFIDENTIAL AND USE IT SOLELY TO ASSESS YOUR SUITABILITY AS A PROSPECTIVE CLIENT. ACCEPTANCE AS A CLIENT WILL BE BASED ON THE INFORMATION FURNISHED BY YOU ON THIS FORM WHICH WILL FORM PART OF ANY EVENTUAL FORMAL CONTRACT FOR SERVICES AND WILL AFFECT THE REFUND CLAUSES OF ANY SUCH CONTRACT. IT IS THEREFORE NECESSARY FOR ALL INFORMATION TO BE COMPLETE, CORRECT, AND TRUTHFUL. A DECISION BY MARITIME IMMIGRATION SERIVES CANADA LTD. AND THEIR AFFILIATE OFFICES IS BASED ON THE PREVAILING LAW AT THE TIME OF THE DECISION; MARITIME IMMIGRATION SERVICES LTD. AND THEIR AFFILIATE OFFICES WILL NOT BE HELD RESPONSIBLE FOR ANY CHANGES IN THE LAW OR REGULATIONS AFTER THE DATE OF DECISION.

 By checking this box, I the undersigned, hereby certify that the information on this form is true and correct and can provide proof upon request. I further declare that I fully understand the contents of this form and aforesaid conditions.