ADDITIONAL FORM FOR LIVE-IN CAREGIVERS

Embassy of Canada in Riyadh, Saudi Arabia

FAMILY NAME: __________________________________ FIRST NAME:______________________________ Date of Birth: ___/___/_______

1- On what basis are you submitting your application?

2- Details of your secondary and post-secondary education: From DD/MM/YYYY To DD/MM/YYYY School Name, Address & Phone number Field of Study Diploma/Certificate

* Use additional sheets if necessary 3- If you have a degree in Nursing, are you licensed? Yes PRC # No

4- Please provide the name, address and phone number where you attended caregiver training (if applicable) Name of School Address Phone/E-mail address

5- What was the exact duration of your caregiver training? From DD/MM/YYYY

To DD/MM/YYYY

6- What TIME and days of the week did you attend your classes? AM Day From To Saturday Sunday Monday Tuesday Wednesday Thursday Friday
LCP August 2010

PM From To

Visa Section, P.O. Box 94321, Riyadh 11693, KSA. Fax: +966-1- 488-9657 Internet: www.saudiarabia.gc.ca E-mail : riyadh.visa@international.gc.ca

7- Did you do any on-the-job training or a practicum? If yes, please indicate the exact duration and time of the week of your on-the-job training or practicum.

Yes (fill out table below)

From DD/MM/YYYY To DD/MM/YYYY

No
Name of Institution/Days of the week/Start and end times (Example: King Khalid Hospital, Mon-Fri, 8am-5pm)

* Use additional sheets if necessary 8- Are you related to your prospective employer in Canada? (E.g. Brother, sister, cousin, in-law, etc.) No ___ Yes ___ Explain: _______________________________________________________________________

9- Did you use an agency/third party for this application? Did you pay fees to a recruiting company?

Yes (fill out table below)

Name of Agency Address Contact Number

No
Fees you paid & currency

I declare that I have answered all questions in this application fully and truthfully.

___________________________ Signature of Applicant

____________________ (dd/mm/ yyyy)

LCP August 2010

Visa Section, P.O. Box 94321, Riyadh 11693, KSA. Fax: +966-1- 488-9657 Internet: www.saudiarabia.gc.ca E-mail : riyadh.visa@international.gc.ca