GENERAL QUESTIONNAIRE

Please answer all questions. If it does not apply to you, write N/A in the space provided.

1. First Name
2. Middle Name
3. Surname
4. Maiden Name
5. Other Name(s) you go by
6. Date of Birth (d/m/y)
7. Town/City of Birth
8. Province/State of Birth
9. Country of Birth
10 Country of Citizenship
.
11 Address
.
12 Home Phone Number
.
13 Work Phone Number
.
14 Other Phone Number (Cell)
.
15 Fax Number
.
16 Email Address
. Eye color
17 Height
.
18 Marital Status (Please check all that
. apply)
Single/Never Married (skip to next question)

Married
Common-law/Conjugal Partner
Annulled Marriage
Legally Separated
Divorced
Widowed
19. Passport Information
Passport Number
Passport Issue & Expiry Date (d/m/y)

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 Country of Issue

20. Language(s) you speak

Full Name of Spouse

21. FAMILY BACKGROUND

Please list ALL family members.

PARENTS Father Mother

First Name
Middle Name
Surname
Maiden Name

Date of Birth

Town of Birth
Country of Birth
Date of Death

Present Address

(Add more paper as necessary)

SIBLING
INFORMATION
Sibling Sibling
22.
First Name
Middle Name
Surname
Maiden Name
Date of Birth
Town/Country of Birth
Gender Male or female
Marital Status
Present Address

23. Education Information

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 Total years of formal education
Highest level achieved (check highest level)
No Secondary
Secondary
Trade/Apprenticeship
College Certificate/Diploma
Bachelor’s Degree
Master’s Degree
Doctorate/PhD

24 Education (add paper as

. necessary)

School/Institution 1 School/Institution 2
Start Date (d/m/y)

End Date (d/m/y)

Name of School

City of School
Country of School

Major
Certificate/Diploma
Major (Course of Study) * (in the case of PhD or Trade

25 Employment
. Current Occupation
Name of Company

Supervisor’s Name
City / Country
Monthly Income (in Canadian $
Dollars)
Employment History (list all jobs for the last 10 years. Please do not leave a gap
between the dates, add paper if needed)

Company
From To Position / City / Monthly
/
M/Y M/Y Job Title Country Income
Employer

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26. Children’s Information

Please include ALL of your children, whether they are dependent on you or not. Please
include all children that you have custody of as well as any children who you do not
have custody of. Please be sure to include children of both partners.

Child #1
Full Name:
First Name: Middle Name:
Last Name:
Sex: Date of Birth:
Height: Eye Color: Citizenship:
Country of residence:
Other Countries with Resident Status:
Marital Status: Relationship to you: DAUGHTER / SON
Will accompany you to Canada? YES / NO

Passport Information:
Passport No. Date of Expiry:
Country of Issue: Identity Card No.:
Languages your child speaks:
Highest Level of education completed:
Current Occupation:

Child #2
Full Name:
First Name: Middle Name:
Last Name:

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 Sex: Date of Birth:
Height: Eye Color: Citizenship:
Country of residence:
Other Countries with Resident Status:
Marital Status: Relationship to you: DAUGHTER / SON
Will accompany you to Canada? YES / NO

Passport Information:
Passport No. Date of Expiry:
Country of Issue: Identity Card No.:
Languages your child speaks:
Highest Level of education completed:
Current Occupation:

Child #3
Full Name:
First Name: Middle Name:
Last Name:

Sex: Date of Birth:

Height: Eye Color: Citizenship:
Country of residence:
Other Countries with Resident Status:
Marital Status: Relationship to you: DAUGHTER / SON
Will accompany you to Canada? YES / NO

Passport Information:
Passport No. Date of Expiry:
Country of Issue: Identity Card No.:
Languages your child speaks:
Highest Level of education completed:
Current Occupation:

Child #4
Full Name:
First Name: Middle Name:
Last Name:

Sex: Date of Birth:

Height: Eye Color: Citizenship:
Country of residence:
Other Countries with Resident Status:
Marital Status: Relationship to you: DAUGHTER / SON
Will accompany you to Canada? YES / NO

Passport Information:

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 Passport No. Date of Expiry:
Country of Issue: Identity Card No.:
Languages your child speaks:
Highest Level of education completed:
Current Occupation:

Please identify the names of the children who will be coming with you to Canada. If a child is not
accompanying you, please specify the reason:

27. IMMIGRATION HISTORY TO ALL COUNTRIES OTHER THAN YOUR

ORIGINAL CITIZENSHIP

How many countries are you and your immediate family members considered a citizen or
permanent resident?

If you and your immediate family members are considered a citizen or permanent resident in
more than one country then please describe:

Have you or any of your immediate family members EVER applied for ANY Visa to ANY
Country in the world? (Ex: Visitor, Study, Work, Immigrant to any country such as USA,
NZ, Australia, England.) YES / NO
If YES, please describe:

Have you or any of your immediate family members ever claimed Refugee or Asylum in any
country in the world? YES / NO
If YES, please describe:

Have you or any of your immediate family members ever been refused ANY Visa to ANY
country in the world? YES / NO
If YES, please explain:

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 Have you or any of your immediate family members ever been refused admission into
Canada? (Ex: Not being granted permission to enter Canada from the USA or by airplane or
ship from any other country)
YES / NO If YES, please explain:

MEMBERSHIP INFORMATION

28 Memberships with Organizations/Groups (Add paper as necessary)

.
Organization/Group 1 Organization/Group 2
Start Date (d/m/y)

End Date (d/m/y)

Name of Group
City of Group
Country of Group
Position Held

29. GOVERNMENT/MILITARY INFORMATION

1. Government Positions, Military Postings (include (Add paper as necessary)

active combat, and all levels of government)
Branch/Jurisdiction 1 Branch/Jurisdiction 2
Start Date (d/m/y)
End Date (d/m/y)
Name of Branch
City of Branch
Country of Branch
Position Held
Duties in Combat

30. ACTIVITY INFORMATION

th
Include all activities which you have done since your 18 birthday or 10 years counting back
from today whichever is most recent.. DO NOT LEAVE GAPS.

Please fill in all addresses where you lived, stayed or work.

From/To (m/y) Activity Position / Title City / Country Name of Company,
Employer, School,

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 Facility, Address

31. ADDRESSES

th
Please list all addresses which you have resided at since your 18 Birthday. Do not leave
any gaps. Please list all addresses in reverse chronological order.

City/ Town/
From To Street Address Province Country
(Month-year) (Month-
year)

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32. HEALTH

a. Have you or any of your family members ever been diagnosed with a serious illness? (Ex: TB,
Diabetes, Mental Health, M.S. are all considered serious to Canada) YES / NO
b. If YES, please describe the medical illness (es) in detail:

33. DETAILS OF CRIMINAL HISTORY:

a. Do you have a criminal record? YES / NO

b. Have you ever been arrested, detained or put in jail? (Ex: DWI or DUI is a criminal offense in
Canada.): YES / NO

c. If YES, please explain in detail:

-Date of the offense or conviction:
-Punishment imposed:
-Was any Probation granted?

d. Do you have a criminal record in more than one (1) country? YES / NO
If yes, please list the country/countries and explain:

e. Have you ever been involved in a war crime, act of genocide, or terrorism? YES / NO
If YES, please explain in full detail:

34. Please list ALL family members living in Canada (their names, full addresses, and
relationship to you):

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