First name
Second name(s)
Family name
Date of birth
Country of birth
Country of residence
Psasport number
Country of passport issuance
Date of issue
Expiry date
Present address
Mobile phone
Home telephone number
Email
Marital status
If you are married, on what date did you get married?
If you are in a common-law relationship, on what date did you begin living together?
How many children do you have?
IF you have children, indicate their ages below.
Indicate whether you have worked in Canada, studied in Canada, visited Canada, or have never been to Canada.
IF you have previously lived in Canada, indicate the dates.
Enter the total amount of funds legally available to you that can be transferred.
If you answered YES to the previous question, specify how these family members are related to you or your spouse or common-law partner, and indicate the Canadian city where they currently live.
French Language Proficiency Test If you have taken a French language proficiency test (TEF or SEL), please answer the following questions.
TEF Canada or TCF Canada?
Date of test
RESULTS:
RESULTS:
RESULTS:
RESULTS:
Education Please provide the following information regarding your post-secondary studies and ALL educational institutions you attended, whether or not you obtained a certificate, diploma or degree.
Diploma 1
From :
To :
Name of school
City/Country
Type of certificate, diploma or degree awarded
Field of study — if there was no specific field, enter “General.”
Diploma 2
From :
To :
Name of school
City/Country
Field of study — if there was no specific field, enter “General.”
Field of study — if there was no specific field, enter “General.”
Diplôme 3
From :
To :
Name of school
City/Country
Type of certificate, diploma or degree awarded
Field of study — if there was no specific field, enter “General.”
Additional diplomas
Employment History Please provide your employment history for the past ten (10) years, beginning with your current employment, and include part-time positions.
Employment 1
From :
To :
City and Country
Job title
Name of company, employer, school, etc.
Street address of CANADIAN employers ONLY
Employment 2
From :
To :
City and country
Job title
Name of company, employer, school, etc.
Street address of CANADIAN employers ONLY
Employment 3
From :
To :
City and country
Job title
Name of company, employer, school, etc.
Street address of CANADIAN employers ONLY
Other Employment
Travel History Please provide details of all your international travel during the past ten (10) years.
City and County
Purpose of travel
From :
To :
City and country
Purpose of travel
From :
To :
City and country
Objet du voyage
From :
To :
Other travels
Additional Questions Please read the following statements carefully and answer honestly. Have you, your spouse or common-law partner, or any of your dependants:
Have you ever been convicted of a criminal offence in any jurisdiction, or are you currently the subject of criminal proceedings?
Have you ever claimed refugee protection in Canada or applied for a Canadian immigrant visa, permanent resident visa, or any other type of visa, such as a temporary resident or visitor visa?
Have you ever been refused refugee status or any other type of visa, such as an immigrant, permanent resident, visitor or temporary resident visa, in Canada or another country?
Have you ever been refused entry to Canada or another country, or been ordered to leave Canada or another country?
Have you participated in an act of genocide, a war crime, a crime against humanity, or the desecration of religious property?
Have you used or planned to use violence to achieve political, social or religious objectives?
Have you ever been a member of a group that is or was involved in organized crime?
Have you suffered from any serious physical or mental illness or disorder?
Is there any other information you consider important to share with the RCIC as part of your preliminary assessment?
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