| *First Name: |
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| Middle Name: |
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| *Last Name: |
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| Address Line 1 |
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| Address Line 2 |
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| City |
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| Province/State: |
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| Postal/Zip Code: |
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| Country: |
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| Daytime Phone: |
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| Evening Phone: |
| Fax: |
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| *E-mail Address: |
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| Date of Birth: |
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| Marital Status: |
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| Number of Children: |
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| Are any dependant children over 22 years old andl enrolled in full-time study?: |
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| Do you or your spouse have any relatives in Canada? If Yes, specify their relation to you |
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| What is your highest level of education? |
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| What is the highest qualification you received? |
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| How many years of full-time education do you have since first grade? |
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| Have you ever studied in Canada? If yes, for how long? |
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| If married, what is your spouse's highest level of education? |
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| What is your current profession? |
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| How many years of work experience do you have? |
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| Do you have arrangement employment in Canada? If Yes, please indicate whether you have a labour market opinon from HRSDC |
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| How proficiently do you speak English? |
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| How proficiently do you read English? |
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| How proficiently do you write in English? |
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| How proficient are your listening skills in English? |
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| How proficiently do you speak French? |
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| How proficiently do you read French? |
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| How proficiently do you write in French? |
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| How proficient are your listening skills in French? |
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| Do you or any member of your family have any past or present medical conditions? If yes, please explain |
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| Do you or any member of your family have any past criminal history in Canada or any other country? If yes, please explain. |
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| Do you or any member of your family have any past immigration history? If yes, please explain. |
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| What is your spouse's highest level of education? |
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| How many years of full-time study did your spouse complete? |
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| Has your spouse held a valid student authorization and, after the age of 17, completed a two year program of study at a post-secondary institution in Canada? |
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| Has your spouse held a valid employment authorization and engaged in at least one year of full-time employment in Canada? |
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| Does your spouse have an offer of employment in Canada? |
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| What is your net worth in Canadian dollars? (Please specify amount) |
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| Was your net worth created by your own endeavors or legally obtained? (eg. inheritence or gift) |
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| Have you owned and operated a business or a percentage of a business within the past five years? If yes, please explain for how long and what percentage. |
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| Have you managed at least five full-time (37.5 hours per week or more) employees in a business over the last two of the last five years? |
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| Please provide any details of your business activities that you deem relevant (eg. your role, duties, responsibilities) |
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| Do you intend to start a business upon your arrival in Canada? If yes, please explain what type |
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| If you do not intend on starting a businss upon your arrival in Canada, please explain what you intend to do. |
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| Pleae provide any further information that you deem is relevant |
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| How were you referred to us?: |
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