Free Assessment Please fill out this Assessment form to the best of your knowledge, so that we can find the best pathway into Canada for you. Name * First Name Last Name Email * Phone * Country (###) ### #### Address * How did hear about us Referral Facebook Instagram Website IF a Referral, who referred you to us Date of Birth MM DD YYYY Country of Birth Country of Residence if different from country of birth If you are a citizen of more than one country, please list ADAPTABILITY FACTORS IF you are married, date of marriage MM DD YYYY If you are in a common-law relationship, what was the date you started living together MM DD YYYY Is your spouse or common-law partner immigrating to Canada with you? Yes No How many children do you have? 0 1 0 0 1 2 3 4 5 6 7 8 9 10 If Yes, please list the ages of your children Have you ever worked, studied or visited Canada? Yes No Did you have a work or study permit in Canada? If YES, dates lived in Canada From MM DD YYYY To MM DD YYYY Please name all countries you have lived in for 6 months or more since the age of 18. Do you or your spouse/common-law partner have any close family members who are permanent residents or citizens of Canada and live in Canada now? Yes No If you answered YES to the above question, please state the relationship of the family member to you and name the city in Canada where they live in. Total amount of funds that you have that are legal and transferable - Do NOT include equity in Real Estate LANGUAGE PROFICIENCY IELTS or CELPIP ? Not Applicable IELTS CELPIP Date of Test MM DD YYYY General or Academic ? Not Applicable General Academic Reading 12.0 11.5 11.0 10.5 10.0 9.5 9.0 8.5 8.0 7.5 7.0 6.5 6.0 5.5 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 Writing 12.0 11.5 11.0 10.5 10.0 9.5 9.0 8.5 8.0 7.5 7.0 6.5 6.0 5.5 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 Listening 12.0 11.5 11.0 10.5 10.0 9.5 9.0 8.5 8.0 7.5 7.0 6.5 6.0 5.5 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 Speaking 12.0 11.5 11.0 10.5 10.0 9.5 9.0 8.5 8.0 7.5 7.0 6.5 6.0 5.5 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 INVESTORS AND ENTREPRENEURS Funds available to invest Please list funds in Canadian Dollars $ Net worth Please list funds in Canadian Dollars $ EDUCATION HISTORY Provide the following information for ALL Education completed. Level of High School Completion ? Select Class/Grade 10 Class/Grade 12 Name of School City/Country Year of completion of High School Select 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 Name of College/University Type of certificate or diploma issued - If you did not complete the program, write "Incomplete" Area of Study - if not specific write General From MM DD YYYY To MM DD YYYY Name of College/University Type of certificate or diploma issued - If you did not complete the program, write "Incomplete" Area of Study - if not specific write General From MM DD YYYY To MM DD YYYY EMPLOYMENT HISTORY Please provide your Employment History for the past 10 years, starting with your current job. Job Title Name of Company/Employer, School, etc. City/Town and Country From MM DD YYYY To MM DD YYYY Job Title Name of Company/Employer, School, etc. City/Town/Village and Country From MM DD YYYY To MM DD YYYY Job Title Name of Company/Employer, School, etc. City/Town/Village and Country From MM DD YYYY To MM DD YYYY Job Title Name of Company/Employer, School, etc. City/Town/Village and Country From MM DD YYYY To MM DD YYYY Job Title Name of Company/Employer, School, etc. City/Town/Village and Country From MM DD YYYY To MM DD YYYY READ THE FOLLOWING CAREFULLY AND ANSWER TRUTHFULLY Have you OR any of your family members ever: Been convicted of, or are you currently charged with, on trial for, or party to a crime or offence, or subject to any criminal proceeding in any country * Yes No If YES, please provide details Previously APPLIED for refugee status in Canada or applied for Canadian Immigration or Permanent Resident Visa OR visitor or Temporary Resident Visa? * Yes No If YES, please provide details Been REFUSED refugee status in, or an Immigration or Permanent Resident Visa or Visitor or Temporary Resident Visa to Canada or any other country? * Yes No If YES, please provide details Been refused admission to or ordered to leave Canada OR any other country? * Yes No If YES, please provide details Been involved in an act of genocide, war crimes or in the commission of a crime against humanity? * Yes No If YES, please provide details Use, planned or advocated the use of armed struggle or violence to reach political, religious or social objectives? * Yes No If YES, please provide details Additional Comments Thank you for your submission. We will be in touch with you in 48 hours.Best Regards,Abhay Bhullar, RCIC
