| *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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| Province/State |
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| Postal/Zip Code |
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| City |
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| *E-mail Address |
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| Country |
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| Daytime Phone |
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| Evening Phone |
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| Fax |
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| Who do you wish to sponsor? |
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| How old are you? |
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| What is your (sponsor) status in Canada? |
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| Where do you (the sponsor) currently reside? |
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| Do you (the sponsor) have a criminal record? |
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| Are you legally married? |
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| If you are not legally married, have you cohabited with your partner in a conjugal relationship for 1 year or more? |
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| If you answered no to the above-noted question, please advise how long you have been in a conjugal relationship with your partner but not living together? |
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| Please provide details with respect to the relationship between the Applicant and Sponsor that may be relevant, including why you have not been able to marry, or live together for 12 continous months |
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| Has the sponsor received social assistance for any reason other than disability? |
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| Is the sponsor an undischarged bankrupt? |
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| Has anyone that the sponsor previously sponsored, or any of their family members, recieved social assistance? |
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| Has the sponsor been ordered to leave Canada? |
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| Does the sponsor currently have a sponsorship application in progress with Citizenship and Immigration Canada? |
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| In Canadian dollars, please indicate your gross employment income and or net business income for the previous calendar year or past 12 months, whichever is greater |
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| If your spouse intends on being a co-signer, please indicate his or her income |
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| How many people in your household, including yourself, are financially dependent upon you? |
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| Do you have a criminal record? |
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| Have you ever had any serious disease or physical or mental disorder? If yes, please explain |
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| Have you ever been refused admission to, or ordered to leave Canada, or any other country? |
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| Have you ever applied for a permanent resident visa? |
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