PRE-QUALIFICATION QUESTIONNAIRE

First Name*

Last Name*

City and Country of residence*

Citizenship (if different from country of residence):

Address

Email*

Birth date

Marital Status

Home phone

Work phone

Cell phone

Have you or any member of your family applied to come to Canada before?

Yes
No

When?

If your application was refused, please specify the reason

In what language do you prefer to be contacted?*

Other Language

What is the best time to contact you; at what telephone number do you prefer to be contacted?*

During working hours (9:00 a.m. to 5:00 p.m.)
After working hours/evening (7:00 p.m. to 9:00 p.m.)
Weekends/Saturday or Sunday
Home phone, Work phone or Cell phone

Education

Highest level of education completed

Name of Degree obtained

KNOWLEDGE OF LANGUAGE

ENGLISH

Reading-English

Writing-English

Speaking-English

Listening-English

FRENCH

Reading-French

Writing-French

Speaking-French

Listening-French

NET WORTH:

The information provided to us in the following questions will be handled with strict confidentiality following Regulation 8.1 of the Code of Professional Ethics of ICCRC (Immigration Consultants of Canada Regulatory Council): “An ICCRC member has a duty to hold in strict confidence at all times all information concerning the personal and business affairs of a Client acquired during the course of practice and should not disclose such information unless disclosure is expressly or implicitly authorized by the Client, required by law or by a tribunal of competent jurisdiction, or is otherwise permitted by this Code”.

Provide an estimate of your total assets (business, real estate, insurance, investments, etc.) in C$.*

Personal assets only

Yes
No

Includes my spouse’s assets.

Yes
No

If you own a business please provide a brief description of industry sector, type of business, # of employees, products or services offered, # of years in business, etc

Provide an estimate of your total liabilities (short-term debt, long-term debt, government loans, etc.) in C$:

Personal liabilities only

Yes
No

Includes my spouse’s liabilities

Yes
No

Indicate which of the following sectors are of interest to you for business investment (check all that apply)

Work Experience

(Last 10 years starting from your most recent employment)

Work Experience 1:

Start date

End date

Occupation/Position

Type:

Employer’s name

Work Experience 2:

Start date

End date

Occupation/Position

Type:

Employer’s name

Work Experience 3

Start date

End date

Occupation/Position

Type:

Employer’s name

FAMILY INFORMATION:

Details of persons to be included in your application

Name, relationship to you, age

Do you or any of your dependants have any medical condition?

Yes
No

If Yes, please explain

Have you or any of your dependants been convicted of a criminal offence?

Yes
No

If Yes, please explain

OTHER INFORMATION:

Which program are you interested in?*

Federal Investor
Federal Entrepreneur
Federal Self-Employed
Do not know

Provincial Nominee Program for:

How did you find about us? Check all that apply

Newspaper ad
Google search
Facebook
Twitter

Other: