CLIENT INFORMATION FORM -

A. Details About You

1. Your Full Name (as shown on your passport or travel document)

2. Your Sex

Male Female Other

Family Name

3. Your Date of Birth

Maiden Name (last name before marriage if applicable)

Alias (other names you have used)

Nick Name (if applicable)

4. Place of Birth

City/Town, Province or State

5. Your Height

Country

6. Colour of Your Eyes

7. Country of Citizenship

8. Your Country of Residence

9. Your Mailing Address (include city and country)

10. Your Residential Address, if different from your mailing address

11. Your Telephone Number
Home

12. Your Email Address (if applicable)

Alternative

14. Details of Your Passport
Passport Number

13. Where do You Intend to Live in Canada?
City/Town

Country of Issue

Province/Territory

Date of Issue

Date of Expiry

15. Your Current Occupation

17. Your Knowledge of English and French
a) Can you communicate in English?

Yes No

16. Your Native Language

b) Can you communicate in French

Yes No

a) If your native language is not English or French, which language do you use most frequently:

English French Neither

c) Which is your first Canadian official language

English French

18. Your Current Marital Status

19. Have you previously been married or in a common-law relationship?

Yes No If 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 paper

a) 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

Name of previous spouse or partner

Date of Birth (yyyy-mm-dd)

20. Details of Your First Entry into Canada and Port of Entry
Date of Entry

Date of Relationship
From

Port of Entry

21. Details of Your Most Recent Entry into Canada and Port of Entry
Date of Entry

Port of Entry

22. Are You a Permanent Resident of the United States with a Valid Green Card?

Yes No

23. Do You have a National Identity Document?

Yes No

If yes:
Document Number

Country of Issue

Issue Date

Expiry Date

24. 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 application

a) 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?

Yes No

b) Previously applied for any of the following for Canada or any other country:
(i) Refugee status

Yes No

(ii) Work Permit

Yes No

(iii) Study Permit

Yes No

(iv) Visitor Visa

Yes No

(v) a Certificate de selection du Quebec (CSQ) to Quebec?

Yes No

(vi) Permanent Resident

Yes No

(vii) Citizenship

Yes No

c) Previously been refused any of the following for Canada or any other country
(i) Refugee status

Yes No

(ii) Work Permit

Yes No

(iii) Study Permit

Yes No

(iv) Visitor Visa

Yes No

(v) a Certificate de selection du Quebec (CSQ) to Quebec?

Yes No

(vii) Other (please indicate box below which application was refused and provide evidence)

Yes No

d) Been refused entry to, or ordered to leave, Canada or any other country?

Yes No

e) Remained beyond the validity of your status, attended school without authorization, or worked in Canada?

Yes No

f) Been involved in an act of genocide, a war crime or in the commission of a crime against humanity?

Yes No

g) Used, planned or advocated the use of armed struggle or violence to reach political, religious or social objectives?

Yes No

h) Witnessed or participated in the ill treatment of prisoners or civilians, looting or desecration of religious buildings?

Yes No

i) 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?

Yes No

j) Been member of an organization that is or was engaged in an activity that is part of a pattern of criminal activity?

Yes No

k) Been detained or put in jail?

Yes No

m) 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?

Yes No

If 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)?

Yes No

26. Are you currently working in Canada under a valid work permit?

Yes No

27. Have you or, if applicable, your accompanying spouse or common-law partner, previously worked full-time in Canada?

Yes No

If yes:

You Provide Evidence

Provide Evidence

28. Have you taken an approved test to assess your proficiency in English or French?

Yes No

If yes, indicate which test and provide test results

(i) CELPIP (ii) IELTS (iii) TEF (iv) TCF

29. Have you or, if applicable, your accompanying spouse or common-law partner, previously completed a program of fulltime study of at least two years at a post-secondary institution in Canada?

Yes No

If yes:

You Provide Evidence

Provide Evidence

30. 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?

Yes No

If yes:

You Provide Evidence

Provide Evidence

31. Amount of unencumbered transferable and available funds you have in Canadian dollars $CAD

EDUCATION

A. Give the number of years of school you successfully completed for each of the following levels of education.

Elementary/ Primary Schoo

Secondary/ High School

University/ College

Trade School or Other Post Secondary School

C. 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.

From YYYY/MM/DD

To YYYY/MM/DD

Name of institution

City and Country

Postal Code

From YYYY/MM/DD

To YYYY/MM/DD

Name of institution

City and Country

Postal Code

From YYYY/MM/DD

To YYYY/MM/DD

Name of institution

City and Country

Postal Code

From YYYY/MM/DD

To YYYY/MM/DD

Name of institution

City and Country

Postal Code

From YYYY/MM/DD

To YYYY/MM/DD

Name of institution

City and Country

Postal Code

Type of Certificate or Diploma Issued

Program of Study

Type of Certificate or Diploma Issued

Program of Study

Type of Certificate or Diploma Issued

Program of Study

Type of Certificate or Diploma Issued

Program of Study

Type of Certificate or Diploma Issued

Program of Study

EMPLOYMENT
A. Provide details on all your current and previous employment history. Please include any time periods of unemployment, if applicable.

From YYYY/MM/DD

To YYYY/MM/DD

Name of Company/Employer

Job Title

Hours Per Week

From YYYY/MM/DD

To YYYY/MM/DD

Name of Company/Employer

Job Title

Hours Per Week

From YYYY/MM/DD

To YYYY/MM/DD

Name of Company/Employer

Job Title

Hours Per Week

From YYYY/MM/DD

To YYYY/MM/DD

Name of Company/Employer

Job Title

Hours Per Week

From YYYY/MM/DD

To YYYY/MM/DD

Name of Company/Employer

Job Title

Hours Per Week

From YYYY/MM/DD

To YYYY/MM/DD

Name of Company/Employer

Job Title

Hours Per Week

From YYYY/MM/DD

To YYYY/MM/DD

Name of Company/Employer

Job Title

Hours Per Week

Country/Territory/ Province

City/Town

Postal Code

Country/Territory/ Province

City/Town

Postal Code

Country/Territory/ Province

City/Town

Postal Code

Country/Territory/ Province

City/Town

Postal Code

Country/Territory/ Province

Postal Code

City/Town

Country/Territory/ Province

Postal Code

City/Town

Country/Territory/ Province

Postal Code

City/Town

PERSONAL 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.

***Note: Please ensure that you do not leave any gaps in time.

From YYYY/MM/DD

To YYYY/MM/DD

Activity/Occupation

City or town and country

Postal Code

From YYYY/MM/DD

To YYYY/MM/DD

Activity/Occupation

City or town and country

Postal Code

From YYYY/MM/DD

To YYYY/MM/DD

Activity/Occupation

City or town and country

Postal Code

From YYYY/MM/DD

To YYYY/MM/DD

Activity/Occupation

City or town and country

Postal Code

From YYYY/MM/DD

To YYYY/MM/DD

Activity/Occupation

City or town and country

Postal Code

From YYYY/MM/DD

To YYYY/MM/DD

Activity/Occupation

City or town and country

Postal Code

From YYYY/MM/DD

To YYYY/MM/DD

Activity/Occupation

City or town and country

Postal Code

From YYYY/MM/DD

To YYYY/MM/DD

Activity/Occupation

City or town and country

Postal Code

From YYYY/MM/DD

To YYYY/MM/DD

Activity/Occupation

City or town and country

Postal Code

From YYYY/MM/DD

To YYYY/MM/DD

Activity/Occupation

City or town and country

Postal Code

From YYYY/MM/DD

To YYYY/MM/DD

Activity/Occupation

City or town and country

Postal Code

Name of company, employer, school, facility, as applicable

MEMBERSHIP OR ASSOCIATION WITH ORGANIZATIONS
A. What organizations gave you supported, been a member of or been associated with? Include any political, social, youth or student organization, trade unions and professional associations. Do not use abbreviations. Indicate the city and country where you were a member. Write "NONE" in the box if you have not been a member of any association/organization.

From YYYY/MM/DD

To YYYY/MM/DD

Name of Organization

Type of Organization

Activities and/or Positions held within Organization

From YYYY/MM/DD

To YYYY/MM/DD

Name of Organization

Type of Organization

Activities and/or Positions held within Organization

From YYYY/MM/DD

To YYYY/MM/DD

Name of Organization

Type of Organization

Activities and/or Positions held within Organization

From YYYY/MM/DD

To YYYY/MM/DD

Name of Organization

Type of Organization

Activities and/or Positions held within Organization

City and country

Postal Code

City and country

Postal Code

City and country

Postal Code

City and country

Postal Code

GOVERNMENT POSITIONS
A. List any government positions (such as civil servant, judge, police officer) you have held. DO NOT USE ABBREVIATIONS. Write "NONE" in the box if you have not held any government position.

From YYYY/MM/DD

To YYYY/MM/DD

Country and Level of Jurisdiction (e.g national, regional)

Department/Branch

Activities and/or Positions held within Organization

From YYYY/MM/DD

To YYYY/MM/DD

Country and Level of Jurisdiction (e.g national, regional)

Department/Branch

Activities and/or Positions held within Organization

From YYYY/MM/DD

To YYYY/MM/DD

Country and Level of Jurisdiction (e.g national, regional)

Department/Branch

Activities and/or Positions held within Organization

From YYYY/MM/DD

To YYYY/MM/DD

Country and Level of Jurisdiction (e.g national, regional)

Department/Branch

Activities and/or Positions held within Organization

MILITARY SERVICE
Provide below details of any military, militia or civil defence unit or service in a security organization or police force (including non-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 country

From YYYY/MM/DD

To YYYY/MM/DD

Branch of service, unit numbers and names of your commanding officers

Rank(s)

Dates and places of any active combat

From YYYY/MM/DD

To YYYY/MM/DD

Branch of service, unit numbers and names of your commanding officers

Rank(s)

Dates and places of any active combat

From YYYY/MM/DD

To YYYY/MM/DD

Branch of service, unit numbers and names of your commanding officers

Rank(s)

Dates and places of any active combat

From YYYY/MM/DD

To YYYY/MM/DD

Branch of service, unit numbers and names of your commanding officers

Rank(s)

Dates and places of any active combat

ADDRESSES
A. List all addresses where you lived in the last 10 years. Do not use P.O. Box addresses. You may use additional sheets if spaces are limited.

From YYYY/MM/DD

To YYYY/MM/DD

Street and number

City or town

Province, State or District

From YYYY/MM/DD

To YYYY/MM/DD

Street and number

City or town

Province, State or District

From YYYY/MM/DD

To YYYY/MM/DD

Street and number

City or town

Province, State or District

From YYYY/MM/DD

To YYYY/MM/DD

Street and number

City or town

Province, State or District

From YYYY/MM/DD

To YYYY/MM/DD

Street and number

City or town

Province, State or District

From YYYY/MM/DD

To YYYY/MM/DD

Street and number

City or town

Province, State or District

From YYYY/MM/DD

To YYYY/MM/DD

Street and number

City or town

Province, State or District

From YYYY/MM/DD

To YYYY/MM/DD

Street and number

City or town

Province, State or District

From YYYY/MM/DD

To YYYY/MM/DD

Street and number

City or town

Province, State or District

Postal Code

Country

Postal Code

Country

Postal Code

Country

Postal Code

Country

Postal Code

Country

Postal Code

Country

Postal Code

Country

Postal Code

Country

Postal Code

Country

B. Have you resided in another country other than country of citizenship? If yes, please provide the details.

Arrival YYYY/MM/DD

Departure YYYY/MM/DD

City/Town

Country

Purpose

Arrival YYYY/MM/DD

Departure YYYY/MM/DD

City/Town

Country

Purpose

Arrival YYYY/MM/DD

Departure YYYY/MM/DD

City/Town

Country

Purpose

Arrival YYYY/MM/DD

Departure YYYY/MM/DD

City/Town

Country

Purpose

Arrival YYYY/MM/DD

Departure YYYY/MM/DD

City/Town

Country

Purpose

Arrival YYYY/MM/DD

Departure YYYY/MM/DD

City/Town

Country

Purpose

Arrival YYYY/MM/DD

Departure YYYY/MM/DD

City/Town

Country

Purpose

Arrival YYYY/MM/DD

Departure YYYY/MM/DD

City/Town

Country

Purpose

Postal Code

Status

Postal Code

Status

Postal Code

Status

Postal Code

Status

Postal Code

Status

Postal Code

Status

Postal Code

Status

TRAVEL
A. List all the places you have travelled.

Arrival YYYY/MM/DD

Departure YYYY/MM/DD

City/Town

Country

Purpose

Arrival YYYY/MM/DD

Departure YYYY/MM/DD

City/Town

Country

Purpose

Arrival YYYY/MM/DD

Departure YYYY/MM/DD

City/Town

Country

Purpose

Arrival YYYY/MM/DD

Departure YYYY/MM/DD

City/Town

Country

Purpose

Arrival YYYY/MM/DD

Departure YYYY/MM/DD

City/Town

Country

Purpose

Arrival YYYY/MM/DD

Departure YYYY/MM/DD

City/Town

Country

Purpose

Arrival YYYY/MM/DD

Departure YYYY/MM/DD

City/Town

Country

Purpose

B. Details About Your Family

Family Name

Spouse/Common-law Partner

Child 1

Child 2

Given Name(s)

Spouse/Common-law Partner

Child 1

Child 2

Maiden Name (last name before marriage, if applicable)

Spouse/Common-law Partner

Child 1

Child 2

Sex: Male/Female

Spouse/Common-law Partner

Child 1

Child 2

Date of Birth (yyyy-mm-dd)

Spouse/Common-law Partner

Child 1

Child 2

Place of Birth (town/city/country)

Spouse/Common-law Partner

Child 1

Child 2

Country of Citizenship

Spouse/Common-law Partner

Child 1

Child 2

Current Country of Residence

Spouse/Common-law Partner

Child 1

Child 2

Other Countries with Resident Status

Spouse/Common-law Partner

Child 1

Child 2

Marital Status

Spouse/Common-law Partner

Child 1

Child 2

Relationship to You

Spouse/Common-law Partner

Child 1

Child 2

Will accompany you to Canada

Spouse/Common-law Partner

Yes No

Child 1

Yes No

Child 2

Yes No

Passport Details:

Passport Number

Spouse/Common-law Partner

Child 1

Country of Issue

Spouse/Common-law Partner

Child 1

Child 2

Date of Expiry

Spouse/Common-law Partner

Child 1

Child 2

Education

Total Number of Years of Formal Education

Spouse/Common-law Partner

Child 1

Child 2

Level of Education

Spouse/Common-law Partner

Child 1

Child 2

Current Occupation

Spouse/Common-law Partner

Child 1

Child 2

Height

Spouse/Common-law Partner

Child 1

Child 2

Colour of Eyes

Spouse/Common-law Partner

Child 1

Child 2

Residential Address

Spouse/Common-law Partner

Child 1

Child 2

Email Address

Spouse/Common-law Partner

Child 1

Child 2

Date of Deceased, if deceased

Spouse/Common-law Partner

Child 1

Child 2

Date of Deceased, if deceased

Spouse/Common-law Partner

Child 1

Child 2

Family Name

Child 3

Child 4

Child 5

Given Name(s)

Child 3

Child 4

Child 5

Maiden Name (last name before marriage, if applicable)

Child 3

Child 4

Child 5

Sex: Male/Female

Child 3

Child 4

Child 5

Date of Birth (yyyy-mm-dd)

Child 3

Child 4

Child 5

Place of Birth (town/city/country)

Child 3

Child 4

Child 5

Country of Citizenship

Child 3

Child 4

Child 5

Current Country of Residence

Child 3

Child 4

Child 5

Other Countries with Resident Status

Child 3

Child 4

Child 5

Marital Status

Child 3

Child 4

Child 5

Relationship to You

Child 3

Child 4

Child 5

Will accompany you to Canada

Child 3

Yes No

Child 4

Yes No

Child 5

Yes No

Passport Details:

Passport Number

Child 3

Child 4

Child 5

Country of Issue

Child 3

Child 4

Child 5

Date of Issue

Child 3

Child 4

Child 5

Date of Expiry

Child 3

Child 4

Child 5

Education

Date of Expiry

Child 3

Child 4

Child 5

Level of Education

Child 3

Child 4

Child 5

Current Occupation

Child 3

Child 4

Child 5

Height

Child 3

Child 4

Child 5

Colour of Eyes

Child 3

Child 4

Child 5

Residential Address

Child 3

Child 4

Child 5

Email Address

Child 3

Child 4

Child 5

Date of Deceased, if deceased

Child 3

Child 4

Child 5

City/Town/Country, if deceased

Child 3

Child 4

Child 5

C. Details About Your Parents

Family Name

Father

Mother

Given Name(s)

Father

Mother

Maiden Name (last name before marriage, if applicable)

Father

Mother

Date of Birth (yyyy-mm-dd)

Father

Mother

Place of Birth (town/city)

Father

Mother

Country of Birth

Father

Mother

Marital Status

Father

Mother

Current Occupation

Father

Mother

Date of Deceased, if deceased

Father

Mother

City/Town/Country, if deceased

Father

Mother

Will accompany you to Canada

Father

Yes No

Mother

Yes No

Residential Address

Father

Mother

Email Address

Father

Mother

D. Details About Your Siblings (include half-and step brothers and sisters)

Family Name

Sibling 1

Sibling 2

Sibling 3

Given Name(s)

Sibling 1

Sibling 2

Sibling 3

Sex: Male/Female

Sibling 1

Sibling 2

Sibling 3

Date of Birth (yyyy-mm-dd)

Sibling 1

Sibling 2

Siblin 3

Place of Birth (town/city/country)

Sibling 1

Sibling 2

Sibling 3

Country of Citizenship

Sibling 1

Sibling 2

Sibling 3

Relationship to You

Sibling 1

Sibling 2

Sibling 3

Current Occupation

Sibling 1

Sibling 2

Sibling 3

Date of Deceased, if deceased

Sibling 1

Sibling 2

Sibling 3

City/Town/Country, if deceased

Sibling 1

Sibling 2

Sibling 3

Residential Address

Sibling 1

Sibling 2

Sibling 3

Email Address

Sibling 1

Sibling 2

Sibling 3

E. Acknowledgment

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By signing this Client Information Form, I,

hereby acknowledge and confirm that all of the information provided herein is correct, true and complete as at the date of signing.

Print Name

Signature

Date (yyyy/mm/dd)