Canada immigration free assessment form : Family Class

First Name *

Last Name *

Gender Select One Male Female

Date of Birth Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December

Current Citizenship:

Present Marital Status Select One Option Married Never Married Divorced Widowed

Permanent Home Address

Current Mailing Address

Email Address *

Telephone (Home)

Telephone (Work)

Highest Qualification Please Select Not Completed Primary/Elementary School Secondary/High School Post Secondary - 1 Year Post Secondary - 2 Years Post Secondary - 3 Years Bachelors Degree - 2 Years Bachelors Degree - 3 Years Bachelors Degree - 4 Years Masters/Doctorate/Ph. D.

Field of Study

Name of College or University

Years of study completed for this program Select One 0 1 2 3 4 5 6 7 8 9 10 Select One Part Time Full Time

Total number of years of full-time study including primary/elementary schooling

Read Select One Option Very Well Moderate With Difficulty Select One Option Very Well Moderate With Difficulty

Write Select One Option Very Well Moderate With Difficulty Select One Option Very Well Moderate With Difficulty

Speak Select One Option Very Well Moderate With Difficulty Select One Option Very Well Moderate With Difficulty

Understand Select One Option Very Well Moderate With Difficulty Select One Option Very Well Moderate With Difficulty

Most Recent Job

Number of years/months at this job Year(s) 0 1 year 2 years 3 years 4 years or more Month(s) 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months

Detailed Duties and Other Information

List any other jobs performed during the past 10 years (include time spent at jobs)

First Name

Last Name (including maiden name if any)

Education Please Select Not Completed Primary/Elementary School Secondary/High School Post Secondary - 1 Year Post Secondary - 2 Years Post Secondary - 3 Years Bachelors Degree - 2 Years Bachelors Degree - 3 Years Bachelors Degree - 4 Years Masters/Doctorate/Ph. D.

Occupation

Children Select One Option 0 1 2 3 4 5 6 7 8 9 10

Do you or your accompanying spouse or common-law partner have a relative in Canada? No Relative in Canada Mother or Father Brother or Sister Daughter or Son Grandmother or Grandfather Niece or Nephew (19 years or older) Aunt or Uncle (Brother/Sister of Parent) Spouse

Have you or your spouse worked full time in Canada for a minimum of one year? Select One Option Yes No

Have you or your spouse studied full time in Canada for a minimum of two years since the age of 18? Select One Option Yes No

Destination in Canada (if known)