IMMIGRATION ASSESSMENT FORM

THE INFORMATION YOU SUPPLY ON THIS FORM WILL BE TREATED IN CONFIDENCE

1 PERSONAL DETAILS

Name

Email Address

Contact Number

Date of Birth(DD/MM/YYYY)

Sex (Male/Female)

Address

Post Code

2 EDUCATION DETAILS
Qualifications obtained from Schools, Colleges and Universities. Please list highest qualification first:
Duration (Include the month
Course/Academic Marks Name of
and year) Qualification Obtained school/College/University with
city/country

From To
3 EMPLOYMENT/WORK EXPERIENCE HISTORY
Employment history, beginning with current or latest employment with complete history of past 10 years.

Duration (Include month and year) Name of the Company with Position held/Designation
City/Country

From To

4 ABILITY IN LANGUAGE

Reading Speaking Listening Writing

English Proficiency Choose an item. Choose an item. Choose an item. Choose an item.

French proficiency Choose an item. Choose an item. Choose an item. Choose an item.

5 FAMILY COMPOSITION

Present marital status Choose an item.

Number of
Number of Children with Age Children Choose an Age
item.
6 SPOUSE INFORMATION (APPLICANTS HUSBAND OR WIFE)

Name

Date of Birth(DD/MM/YYYY)

Sex (Male/Female)

7 SPOUSE EDUCATION DETAILS

Qualifications obtained from Schools, Colleges and Universities. Please list highest qualification first:
Duration (Include the month
Course/Academic Marks Name of
and year) Qualification Obtained school/College/University with
city/country

From To

8 SPOUSE ABILITY IN LANGUAGE

Reading Speaking Listening Writing

English Proficiency Choose an item. Choose an item. Choose an item. Choose an item.

French proficiency Choose an item. Choose an item. Choose an item. Choose an item.
9 EMPLOYMENT/WORK EXPERIENCE HISTORY OF SPOUSE
Employment history, beginning with current or latest employment with complete history of past 10 years.

Duration (Include month and year) Name of the Company with Position held/Designation
City/Country

From To

10 OTHER DETAILS

How many years of Work experience have you

obtained INSIDE CANADA within the last 10 Choose an item.
years?

How many years of Work experience has your

spouse obtained INSIDE CANADA within the last Choose an item.
10 years?
Do you have a blood relative who is living in
Canada, is over the age of 18? Choose an item.
 Statement of Protection of Personal Information
At Croyez, we understand and respect that your privacy is important to you. We limit the collection of your
Personal Information to what is necessary to fulfil the identified purposes. We use and share Personal
Information that you provide to us only in ways that we tell you about. We safeguard Personal Information
that you provide to us to prevent it from being used and shared for other purposes.

Declaration
This declaration covers the information that I have provided on this form and all the information submitted
in my application for permanent resident visa.

I declare that the information I have given is truthful, complete and correct.
I will notify the representative of any change in answers given on this form before the submission
of application to Immigration Department (CIC), CANADA.
I understand that any false statements or concealment of a material fact may be grounds for my
prosecution or removal.
I acknowledge that I have read the notice on the Statement of Protection of Personal Information
in the section above.
I further acknowledge that by saving this document and sending the same to my legal
representative electronically, constitute my consent to use the information and no physical
signature is required.