Questionnaire

Please answer all questions. If it does not apply to you, write N/A in the space provided.
Part 1 PERSONAL INFORMATION for the APPLICANT
1. 2. 2. 3. 4. 5. 6. 7. 8. 9. 10 . 12 . 13 . 14 . 15 . 16 First Name Middle Name Surname Maiden Name Other Name(s) you go by Date of Birth (d/m/y) Town/City of Birth Province/State of Birth Country of Birth Country of Citizenship Address Home Phone Number Work Phone Number Other Phone Number (Cell) Fax Number Email Address

17 . 18 . 18 .

Eye color Height Marital Status Single/Never Married (skip to next question) Married (pls. specify the date of marriage) Common-law/Conjugal Partner ( date you entered common-law/conjugal relationship) Annulled Marriage (Pls. indicate the date) Legally Separated (Pls. indicate the date) Divorced (Pls. indicate the date) Widowed Name of Previous Partner (If Applicable) Passport Information Passport Number Passport Expiry Date (d/m/y) Country of Issue (Please check all that apply)

19. 20.

Language(s) you speak FAMILY BACKGROUND Please list ALL family members. Please also indicate family members who are deceased. Be sure to include the date of death. PARENTS First Name Middle Name Surname Maiden Name Date of Birth Father Mother

Town of Birth Country of Birth Date of Death Present Address

21.

SIBLING INFORMATION

(add more paper as necessary) Sibling Sibling

First Name Middle Name Surname Maiden Name Date of Birth Town of Birth Country of Birth Marital Status Present Address

22 .

Education Information Total years of formal education

Highest level achieved (check highest level) No Secondary Secondary Trade/Apprenticeship College Certificate/Diploma Bachelors Degree Masters Degree Doctorate/PhD 23 . Education (add paper as necessary)

School/Institution 1 Start Date (d/m/y) End Date (d/m/y) Name of School City of School Country of School

School/Institution 2

Major Certificate/Diploma Major (Course of Study) * (in the case of PhD or Trade 24. Employment Current Occupation Name of Company Supervisors Name City / Country Monthly Income (in $ Canadian Dollars) Employment History (list all jobs for the last 10 years. Add paper if needed) Company / Employer Position / Job Title

From M/Y

To M/Y

City / Country

Monthly Income

25.

Childrens 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. Full Name: First Name: Last Name: Middle 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. Country of Issue: Languages your child speaks: Highest Level of education completed: Current Occupation: Date of Expiry: Identity Card No.:

Full Name: First Name: Last Name:

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

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:

26. 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 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: Country

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

country

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 27. Memberships with Organizations/Groups Organization/Group 1 Start Date (d/m/y) End Date (d/m/y) Name of Group City of Group Country of Group Position Held 28. GOVERNMENT/MILITARY INFORMATION 8 Government Positions, Military Postings (include 1. active combat, and all levels of government) Branch/Jurisdiction 1 Start Date (d/m/y) End Date (d/m/y) Name of Branch City of Branch (add paper as necessary) Branch/Jurisdiction 2 (add paper as necessary) Organization/Group 2

Country of Branch Position Held Duties in Combat 29. ACTIVITY INFORMATION

Include all activities which you have done since your 18th birthday.. DO NOT LEAVE GAPS. Also include all trips, holidays and if employed or unemployed. Give exact dates and make sure not to leave any gaps in between the dates. Please fill in all addresses where you lived, stayed or work. Whichever is applicable. Name of Company, From/To (m/y) Activity Position / Title City / Country Employer, School, Facility

30. ADDRESSES Please list all addresses which you have resided at since your 18th Birthday. Do not any gaps. Please list all addresses in reverse chronological order. From To (monthStreet Address Town, City, leave

Country

(monthyear)

year)

Province

31.
a. b.

HEALTH
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 If YES, please describe the medical illness (es) in detail:

32. a. b. c.

DETAILS OF CRIMINAL HISTORY: Do you have a criminal record? YES / NO Have you ever been arrested, detained or put in jail? (Ex: DWI or DUI is a criminal offense in Canada.): YES / NO If YES, please explain in detail: -Date of the offense or conviction -Punishment imposed -Was any Probation granted? Do you have a criminal record in more than one (1) country? YES / NO If yes, Please list the country/countries and explain: Have you ever been involved in a war crime, act of genocide, or terrorism? YES / NO If YES, please explain in full detail:

d. e.

33.

SPOUSES INFORMATION:

Part 2 PERSONAL INFORMATION for the SPOUSE

34 . 35 . 36 . 37 . 38 39 . 40 . 41. 42 43 . 44 45 . 46 . 47 . 48 . 49 . 50 . 51 . 52 . First Name Middle Name Surname Maiden Name Other Name(s) you go by Date of Birth (d/m/y) Town/City of Birth Province/State of Birth Country of Birth Country of Citizenship Address Home Phone Number Work Phone Number Other Phone Number (Cell) Fax Number Email Address Eye color Height Marital Status Single/Never Married (skip to next question) Married (pls. specify the date of marriage) (Please check all that apply)

Common-law/Conjugal Partner ( date you entered common-law/conjugal relationship) Annulled Marriage (Pls. indicate the date) Legally Separated (Pls. indicate the date) Divorced (Pls. indicate the date) Widowed Name of Previous Partner (If Applicable) Passport Information Passport Number Passport Expiry Date (d/m/y) Country of Issue 53. 54. Language(s) you speak FAMILY BACKGROUND Please list ALL family members. Please also indicate family members who are deceased. Be sure to include the date of death. PARENTS First Name Middle Name Surname Maiden Name Date of Birth Town of Birth Country of Birth Date of Death Present Address Father Mother

55.

SIBLING INFORMATION

(add more paper as necessary) Sibling Sibling

First Name Middle Name Surname Maiden Name Date of Birth Town of Birth Country of Birth Marital Status Present Address

56 .

Education Information Total years of formal education

Highest level achieved (check highest level) No Secondary Secondary Trade/Apprenticeship College Certificate/Diploma Bachelors Degree Masters Degree Doctorate/PhD 57 . Education (add paper as necessary) School/Institution 1 Start Date (d/m/y) End Date (d/m/y) Name of School City of School School/Institution 2

Country of School Major Certificate/Diploma Major (Course of Study) * (in the case of PhD or Trade 58. Employment Current Occupation Name of Company Supervisors Name City / Country Monthly Income (in Canadian Dollars) $

ACTIVITY INFORMATION Include all activities which you have done since your 18th birthday.. DO NOT LEAVE GAPS. Also include all trips, holidays and if employed or unemployed. Give exact dates and make sure not to leave any gaps in between the dates. Please fill in all addresses where you lived, stayed or work. Whichever is applicable. Name of Company, From/To (m/y) Activity Position / Title City / Country Employer, School, Facility

59. ADDRESSES Please list all addresses which you have resided at since your 18th Birthday. Do not any gaps. Please list all addresses in reverse chronological order. From (monthyear) To (monthyear) Street Address Town, City, Province leave

Country

60.
a. b.

HEALTH
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 If YES, please describe the medical illness (es) in detail:

61. a. b. c.

DETAILS OF CRIMINAL HISTORY: Do you have a criminal record? YES / NO Have you ever been arrested, detained or put in jail? (Ex: DWI or DUI is a criminal offense in Canada.): YES / NO If YES, please explain in detail: -Date of the offense or conviction -Punishment imposed -Was any Probation granted? Do you have a criminal record in more than one (1) country? YES / NO If yes, Please list the country/countries and explain: Have you ever been involved in a war crime, act of genocide, or terrorism? YES / NO If YES, please explain in full detail:

d. e.