A. Details About You1. Your Full Name (as shown on your passport or travel document)Family NameGiven Name(s)Maiden Name(last name before marriage if applicable)Nick Name(if applicable)4. Place of BirthCityState/ProvinceCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwe7. Country of Citizenship9. Your Mailing Address(include city and country)11. Your Telephone NumberHomeAlternative13. Where do You Intend to Live in Canada?City/TownProvince/Territory15. Your Current Occupation16. Your Native LanguageEnglishFrenchNeithera) If your native language is not English or French, which language do you use most frequently:2. Your SexMaleFemaleOther3. Your Date of BirthDateYear-Month-DayAlias(other names you have used)5. Your Heightcmft6. Colour of Your Eyes8. Your Country of Residence10. Your Residential Address, ifdifferent from your mailingaddress12. Your Email Address(if applicable)14. Details of Your PassportPassport NumberCountry of IssueDate of IssueDate of Expiry17. Your Knowledge of English and Frencha) Can you communicate in English?YesNob) Can you communicate in FrenchYesNoc) Which is your first Canadian official languageEnglishFrench18. Your Current Marital StatusNever MarriedMarriedWidowedLegally SeparatedAnnulled MarriageDivorcedCommon-lawa) If you are married or in a common-law relationship, Date of Birth (yyyy-mm-dd) provide the date on which you were married or entered into the common-law relationship(yyyy-mm-dd)20. Details of Your First Entry into Canada and Port of EntryDate of EntryPort of Entry22. Are You a Permanent Resident of the United States with a Valid Green Card? YesNo19. Have you previously been married or in a common-law relationship?YesNoIf Yes, give the following details for each previous spouse or partner. If you do not have enough space, provide details on a separate sheet of paperName of previous spouse or partnerDate of Birth(yyyy-mm-dd)Type of RelationshipMarriageCommon-law unionDate of RelationshipFromTo21. Details of Your Most Recent Entry into Canada and Port of EntryDate of EntryPort of Entry23. Do You have a National Identity Document?NoYesIf yes:Document NumberCountry of IssueIssue DateExpiry DateField Group24. Have you, or any of your family members listed in your application for temporary and/or permanent residence in Canada, ever: Failing to answer these questions truthfully, may result in a refusal of your applicationa) Been convicted of, or are you currently charged with, on trial for, or partly to a crime or offence, or subject to any criminal proceedings in any country?YesNob) Previously applied for any of the following for Canada or any other country:(i) Refugee statusYesNo(ii) Work PermitYesNo(iii) Study PermitYesNo(iv) Visitor VisaYesNo(v) a Certificate de selection du Quebec (CSQ) to Quebec?YesNo(vi) Permanent ResidentYesNo(vii) CitizenshipYesNoc) Previously been refused any of the following for Canada or any other country (i) Refugee statusYesNo(ii) Work PermitYesNo(iii) Study PermitYesNo(iv) Visitor VisaYesNo(v) a Certificate de selection du Quebec (CSQ) to Quebec?YesNo(vi) Permanent ResidentYesNo(vii) OtherYesNo(please indicate box below which application was refused and provide evidence)d) Been refused entry to, or ordered to leave, Canada or any other country?YesNoe) Remained beyond the validity of your status, attended school without authorization, or worked in Canada? YesNof) Been involved in an act of genocide, a war crime or in the commission of a crime against humanity? YesNog) Used, planned or advocated the use of armed struggle or violence to reach political, religious or social objectives? YesNoh) Witnessed or participated in the ill treatment of prisoners or civilians, looting or desecration of religious buildings? YesNoi) Been associated with a group that used, uses, advocated or advocates the use of armed struggle or violence to reach political, religious or social objectives?YesNoj) Been member of an organization that is or was engaged in an activity that is part of a pattern of criminal activity? YesNok) Been detained or put in jail?YesNol) Had any serious disease or physical or mental disorder? YesNom) Within the past two years have you or any family member had tuberculosis of the lungs or been in close contact with a person with tuberculosis?YesNoIf you have answered yes to questions 24 (a) to (m) above, please provide details and evidence.25. Do you have an offer of employment in Canada approved by Human Resources Development Canada (HRDC)? YesNo26. Are you currently working in Canada under a valid work permit? YesNo27. Have you or, if applicable, your accompanying spouse or common-law partner, previously worked full-time in Canada?YesNoIf yes:YouYour Spouse or Common-Law PartnerProvide Evidence28. Have you taken an approved test to assess your proficiency in English or French? If yes, indicate which test and provideYesNotest results(i) CELPIP(ii) IELTS(iii) TEF(iv) TCF29. Have you or, if applicable, your accompanying spouse or common-law partner, previously completed a program of full time study of at least two years at a post-secondary institution in Canada?YesNoIf yes:YouYour Spouse or Common-Law PartnerProvide Evidence30. Do you, if applicable, your accompanying spouse or common-law partner, have a relative living in Canada who is a citizen or a permanent resident of Canada?YesNoIf yes:YouYour Spouse or Common-Law PartnerProvide EvidenceRelationshipMother/FatherDaughter/SonGrandmother/GrandfatherGranddaughter/GrandsonSister/BrotherNiece/NephewAunt/UncleSpouse or Common-Law Partner31. Amount of unencumbered transferable and available funds you have in Canadian dollars$CADField GroupEDUCATIONA. Give the number of years of school you successfully completed for each of the following levels of education.Elementary/ Primary SchoolSecondary/ High SchoolUniversity/ CollegeTrade School or Other Post Secondary SchoolB. What is your highest level of completed education?Non SecondarySecondaryBachelor's DegreeMaster's DegreeTrade/ApprenticeshipPh.DNon-University Certificate/DiplomaC. Give details of all secondary and post-secondary education (including university, college and apprenticeship training) you have had. You may use additional sheets if spaces are limited.C. Give details of all secondary and post-secondary education (including university, college and apprenticeship training) youhave had. You may use additional sheets if spaces are limited.EMPLOYMENTHours Per WeekCountry/Territory/ ProvinceCity/TownPostal CodePERSONAL HISTORY A. Provide the details of your personal history for the last 10 years ago. Start with the most recent information. Under "Activity",write your occupation or job title if you were working. If you were not working, provide information on what you were doing(for example: unemployed, studying, travelling, in detention, etc). You may use additional sheets if space is limited.From YYYY/MM/DDTo YYYY/MM/DDActivity/OccupationCity or town and countryPostal CodeName of company, employer, school, facility, as applicableMEMBERSHIP OR ASSOCIATION WITH ORGANIZATIONSMEMBERSHIP OR ASSOCIATION WITH ORGANIZATIONSFrom YYYY/MM/DDTo YYYY/MM/DDName of OrganizationType of OrganizationFrom YYYY/MM/DDTo YYYY/MM/DDName of institutionCity and CountryPostal CodeType of Certificate or Diploma IssuedProgram of StudyA. Provide details on all your current and previous employment history. Please include any time periods of unemployment, ifapplicable.From YYYY/MM/DDTo YYYY/MM/DDName of Company/EmployerJob TitleActivities and/or Positions held within OrganizationCity and countryPostal CodeGOVERNMENT POSITIONS A. List any government positions (such as civil servant, judge, police officer) you have held. DO NOT USEABBREVIATIONS. Write "NONE" in the box if you have not held any government positionFrom YYYY/MM/DDTo YYYY/MM/DDCountry and Level of Jurisdiction (e.g national, regional)Department/BranchActivities and/or Positions held within OrganizationMILITARY SERVICE Provide below details of any military, militia or civil defence unit or service in a security organization or police force (includingnon-obligatory national service, reserve or volunteer units) for each of the countries in whose armed forces you served. Write"NONE" in the box if you have not undertaken military service.Name of countryFrom YYYY/MM/DDTo YYYY/MM/DDBranch of service, unit numbers and names of your commanding officersRank(s)Dates and places of any active combatADDRESSESA. List all addresses where you lived in the last 10 years. Do not use P.O. Box addresses. You may use additional sheets ifspaces are limited.From YYYY/MM/DDTo YYYY/MM/DDStreet and numberCity or townProvince, State or DistrictPostal CodeCountryB. Have you resided in another country other than country of citizenship? If yes, please provide the details.Arrival YYYY/MM/DDDeparture YYYY/MM/DDCity/TownCountryPurposePostal CodeStatusTRAVELA. List all the places you have travelled.Arrival YYYY/MM/DDDeparture YYYY/MM/DDCity/TownCountryPurposeB. Details About Your FamilyD. Details About Your Siblings (include half-and step brothers and sisters) E. Acknowledgment By signing this Client Information Form, Ihereby acknowledge and confirm thatall of the information provided herein is correct, true and complete as at the date of signing.Print NameDate (yyyy/mm/dd) Send Message
