Initial Assessment Form

Please complete this form. If a question is NOT applicable to you, please indicate it with N/A.
Failure to provide a completed answer for the questions will result in delay of process.
If you have any questions of concerns, please contact us.

Refer by

A. PERSONAL DETAILS

1. Your Full Name as shown on your Passport.

Family Name (Last Name) *

Middle Name (If Applicable)

Given Name (First Name) *

Your Full name written in your native language or script (e.g., Arabic, Cyrillic, Chinese, Korean, etc.) *

2. Your Past Name
If different from above and If you have used any other name in the past/current legal document. (Example: Nickname, maiden name, alias, etc.)
NoYes (Fill below)

Given Name (First Name)

Middle Name(s)

Family Name (Last Name)

Given Name (First Name)

Middle Name(s)

Family Name (Last Name)

3. Do you have Unique Client Identifier (UCI) number?

4. Your Sex (Gender) * MaleFemaleUnknownAnother Gender

5. Your Date of Birth *

6. Your Place of Birth (City/Town & Country) *

7. Citizenship

Current Citizenship #1 *

Current Citizenship #2

8. Current country or territory of residence

Country/Territory *

Status (Citizen, Worker, Student, PR, or Other) *

If Other

From*

To*

9. Previous countries or territories of residence

During the past five years have you lived in any country or territory other than your country of citizenship or your current country or territory of residence (indicated above) for more than six months? * NoYes (Fill below)

Country/Territory

Status (Citizen, Worker, Student, PR, or Other)

If Other

From

Country/Territory

Status (Citizen, Worker, Student, PR, or Other)

If Other

From

10. Current country or territory of residence

Country/Territory *

Status (Citizen, Worker, Student, PR, or Other) *

If Other

From *

To *

11. Marital Status

b) (If you are married or in a common-law relationship) Provide the date on which you were married or entered into the common-law relationship.

c) Provide the details of your current Spouse/Common-law partner

Given Name (First Name)

Family Name (Last Name)

Canadian Citizen or Permanent Resident? NoYes

12. Have you previously been married or in a common-law relationship? (Y/N) *MarriedCommon-lawNo

If you have, provide information below.

Given Name (First Name)

Family Name (Last Name)

Date of Birth

Relationship Start Date

Relationship End Date

13. Children

a) Do you have Children? (Y/N) *YesNo

b) How many Children do you have?

c) If you have children, please provide their names and ages

14.
a)Indicate whether you have: worked in/studied in/visited/never been to Canada *

b) Have you ever had a work or study permit to Canada? (Y/N) * YesNo

c) If you lived in Canada before, what were the date?

d) List the total amount of funds you have that are legal and transferrable (Do NOT include equity in real estate) *

e) Do you or your partner have close family members who are permanent residents or citizens of Canada and live in Canada now? (Y/N) *YesNo

f) If you answered YES to the question above, please state the relationship of the family member to you/your partner and the name of the city in Canada in which he/she resides.

B. Language(s)

Native language/Mother Tongue *

Have you taken a test from a designated testing agency to assess your proficiency in English or French? * NoYes

English Language Test - If yes, pease complete the following:

Test Result: Reading

Test Result: Writing

Test Result: Speaking

Test Result: Listening

Levels of English or French Language Proficiency - If no, please check one of the items below: *

C. Passport

Passport Number *

Country or Territory of Issue *

Issue Date *

Expiry Date *

For this trip, will you use a passport issued by the Ministry of Foreign Affairs in Taiwan that includes your personal identification number? *NoYes

For this trip, will you use National Israeli Passport? *NoYes

D. National Identity Document

Do you have a national identity document? * NoYes (Fill below)

Document Number

Country of Issue

Issue Date

Expiry Date

E. US PR Card

Are you a lawful Permanent Resident of the United States?* NoYes (Fill Below)

U.S. Citizenship and Immigration Services (USCIS) number

Expiry Date

F. Contact Information

Current Mailing Address *

Residential Address *Same as mailing address? YesNo

Telephone No.*Canada/USOther

HomeCellBusiness

Alternate Telephone No.

Fax No.

E-mail address *

G. COMING INTO CANADA

1. Your original entry to Canada

Date *

Place *

The original purpose for coming to Canada *

If Other

2. Your most recent entry to Canada (if not the same as original entry)

Date

Place

Reason for Entry

3. If applicable, provide the document number of the most recent Visitor Record, Study Permit, Work Permit or Temporary Resident Permit issued to you.

Document Number

4. Have you been issued a certificate under the Provincial Nominee Program?

NoYes

H. DETAILS OF VISIT TO CANADA (for visitor)

Purpose of your visit *

If Other

Indicated how long you plan to stay: *

From *

To *

Funds available for your stay(CAD): *

Name, address and relationship of any person(s) or institution(s) you will visit:

Name

Relationship to you

Address in Canada

Name

Relationship to you

Address in Canada

Name

Relationship to you

Address in Canada

Name

Relationship to you

Address in Canada

I. Education History

1. Education History

Have you had any post secondary education (including university, college or apprenticeship training)? * NoYes (Fill below)

From

Field and level of study

Schoo/Facility Name

City/Town

Country or Territory

Province/State

Number of years of school successgully completed for each of the following levels of education.

Elementary/Primart School

Secondary/High School

University/Colletge

Trade school or other post-secondary school

Education History 01

From

Schoo/Facility Name

City/Town

Country

Field and level of study (Major)

Degree/Diploma/Certificate/Not Completed

Full-time or Part-time

Education History 02

From

Schoo/Facility Name

City/Town

Country

Field and level of study (Major)

Degree/Diploma/Certificate/Not Completed

Full-time or Part-time

Education History 03

From

Schoo/Facility Name

City/Town

Country

Field and level of study (Major)

Degree/Diploma/Certificate/Not Completed

Full-time or Part-time

J. Employment History
Please provide your employment history for the past 10 years including if you have held any goverment positions (such as civil servant, judge, police officer, mayor, member of pariliament, hospital administrator, employee of a security organization). Do not leave gaps. If retired, not working, or studying, please indicate. If you are retired, please provide the 10 years before your retirment.

Employment History 01

From

Current Activity/Occupation

Company/Employer/Facility name

City or Town/Country

Country or Territory

Province/State

Employment History 02

From

Current Activity/Occupation

Company/Employer/Facility name

City or Town/Country

Country or Territory

Province/State

Employment History 03

From

Current Activity/Occupation

Company/Employer/Facility name

City or Town/Country

Country or Territory

Province/State

Employment History 04

From

Current Activity/Occupation

Company/Employer/Facility name

City or Town/Country

Country or Territory

Province/State

K. Travel History
Since the age of 18 or during the past five years, whichever is more recent, have you travelled to any county or territory other than the country of your citizenship or your curreny country or territory of residence?

Travel History 01

From

Visa Issued (Y/N)YesNo

Country or Territory

Location

Purpose of Trip

Travel History 02

From

Visa Issued (Y/N)YesNo

Country or Territory

Location

Purpose of Trip

Travel History 03

From

Visa Issued (Y/N)YesNo

Country or Territory

Location

Purpose of Trip

Travel History 04

From

Visa Issued (Y/N)YesNo

Country or Territory

Location

Purpose of Trip

L. Background Information
Please answer the following questions truthfully. Please check one of the following options (Yes or No).

1. Medical Question

a) Within the past two years, have you or a family member ever had tuberculosis of the lungs or been in close contact with a person with tuberculosis? * NoYes

b) Do you have any physical or mental disorder that would require social and/or health services, other than medication, during a stay in Canada? * NoYes

c) If you answered "Yes" to question 1a) or 1b), please provide details and the name of the family member (If applicable)

2. Validity and Status

a) Have you ever remained beyond the validity of your status, attended school without authorization or worked without authorization in Canada? * NoYes

b) Have you ever been refused a visa or permit, denied entry or ordered to leave Canada or any other country or territory? * NoYes

c) Have you previously applied to enter or remain in Canada? * NoYes

d) If you answered “yes” to question 2a), 2b) or 2c), please provide details.

3. Criminal Background

a) Have you ever committed, been arrested for, or been charged with or convicted of any criminal offence in any country or territory?* NoYes

b) If you answered "yes" to question 3a), please provide details.

4. Military Background

a) Did you serve in any military, militia, or civil defence unit or serve in a security organization or police force (including non obligatory national service, reserve or volunteer unit)? * NoYes

b) If you answered "yes" to question 4a), please provide date of service and countries or territories where you served.

5. Political / Religious Organization Background

a) Are you, or have you ever been a member or associated with any political party, or other group or organization which has engaged in or advocated violence as a means to achieving a political or religious objective, or which has been associated with criminal activity at any time? * NoYes

6. Witness of ill treatment

a) Have you ever witnessed or participated in the ill treatment of prisoners or civilians, looting or desecration of religious buildings? * NoYes

Is there any other information that you feel is important to share as part of your preliminary assessment?

M. Declaration

I declare that the information I have given is truthful, complete and correct.
I understand that any false statements or concealment of a material fact may be grounds for prosecution or removal from Government of Canada.
I understand that information not provided within time required will be subject to delay of process and/or may not able to submit within expiry date.
I understand that KSP Immigration Consulting Inc. will use the information to assist my application on my behalf.
I understand that providing any false information or failure to provide required information may result in enforcement action being taken by the Government of Canada, including but not limited to, a future five-year ban.

I understand that the information I have provided on this form will be used for all application related to signed below.

Print Your Full Legal Name*

Date

Additional Documents

Passport Copy (Maximum Upload Size: 5mb)

Resume (Maximum Upload Size: 5mb)

Additional Documents 01 (Employer Reference Letter, Education Transcript, etc. Maximum Upload Size: 5mb)

Additional Documents 02 (Employer Reference Letter, Education Transcript, etc. Maximum Upload Size: 5mb)

Additional Documents 03 (Employer Reference Letter, Education Transcript, etc. Maximum Upload Size: 5mb)

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