EXPRESS ENTRY

Name of Client:

File Number: Occupation:

Amount required to be shown for your application (Canadian $) =

Please read the following instructions before filling the form:

 This is our source document for your Personal information. Kindly ensure all the information
is accurate, truthful and supported by documentation. (special attention to the spellings)
 Please fill in the blank boxes in front or bottom, save it and send back to us by email.
 Use the mouse or tab button to navigate between the boxes.
 If the text is longer, do not bother, just continue writing. But do not write anything outside
the boxes.
 Please do not make changes to the title texts and any pre-filled information
 Whichever field has no information in your case or does not apply to you, please mention
"N/A"
 IMPORTANT: Please also send copy of your passport (if you have not done so before) and for
all the members who are immigrating.
 We shall revert with further questions, if any.

Protection of personal information

The personal information appearing on this form, and in any documents that must be appended to it, is required for
processing your application for a selection certificate and the application of the Act respecting immigration to Canada, the
Regulation respecting the selection of foreign nationals, the Regulation respecting the immigration consultants and their
administrative regulations. Your personal information is confidential and may not be disclosed without your consent unless
explicitly authorized by you.

DECLARATION

I declare that the information contained in this application and appended documents, if any, is complete and accurate and 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 acknowledge that I have read the notice on the 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.
If you misrepresented yourself (gave us false information or left out important details), your application will be refused. You
could be found inadmissible, and you could be barred for five years from applying for permanent resident status.

X
Name:

Page 1 of 9
 Principal Applicant - Personal Information Form

1 - Personal Information
First Name & Middle Name :
Last Name at birth :

Last Name after marriage, if applicable :

Sex: Date of Birth : Place of Birth :

Native Language :

Complete Address of Current Residence with Postal code & Phone Numbers:

Passport Nº: Date of Issue: Date of Expiry:

What is your Current Status ( Studying / Working / Unemployed / Other ) :

2 - Family Composition
Present marital Status (Single / Married / De facto Spouse / Separated / Divorced / Widowed ):

Date of Marriage :
Have you been Married more than once (if yes, give details) :

Your Height in cms :

Colour of your Eyes :
Mother’s Family Name at her Birth :
Mother’s date of Death (if deceased) :
Fathers’ Date of Death (if deceased) :
Any Remarks, if you want to make :
DETAILS of Children (if any ) :
Full Name Date & Passport Place of Date of Date of
(as per Place of No. issue issue Expiry
passport) Birth

Name of the Children Height in Colour of eyes Number of years of

cms completed education

3 – Your Education Details of Secondary and post Secondary

Give number of years of completed years :
Elementary Secondary/ College / Diploma or
school High School University Trade school

(Please give all the information correctly and with full details. Do not use short forms for the diploma or
degree )
** If you require Professional registration/license to practice your profession provide the FIRST date of registration:
mm/dd/yy
Duration Academic & Name of
From To Professional Specialization School/University with
yy/mm yy/mm Qualification City and Country
4 – Personal History
Provide the details of your personal history since the age of 18, or past 10 years whichever
comes first. If you were/are not working give studying or unemployed or travelling etc.
Start with the most recent and go backwards.
Please ensure that there is no gap in the dates.

Duration City or Town

From To And Country Name of employer /
Activity in Detail
Yy/mm/ Yy/mm/
School etc as applicable
dd dd
5 - List every place where you have lived in since the age of 18 or past 10 years which
ever is earlier.
Length of Time CITY (with PROVINCE POSTAL COUNTRY
house /STATE CODE
From To number and
YY/MM/DD YY/MM/DD
Street)
6 - Work History
Total number of years of experience with complete history of ONLY past 10 years:
VERY IMPORANT : In the last column, please start with number of hours per week, Job title and
6 - Ability
Principal in Language
Tasks – ENGLISH
performed during the work(IELTS test Results)
City and Country where you have appeared for IELTS :
Duration
Date of IELTS Examination : Name of the
From To Designation (job title) and Job duties
Band
Yy/mmin SPEAKING:
Yy/mm/ Company
/dd in LISTENING:
Band dd

Band in READING:
Band in WRITING:
7 – Have you ever Applied for any kind of visa to Canada? if yes, give details below :
7 – In which city or region of Canada you plan to Live?

8 - Do you have any relatives in Canada? If yes give exact details of relation and also the
status of your relative in Canada.

9 - Family Please give details of your :

- parents,
Details : - Children (if any), (include step children, if any)
- Brothers and Sisters (include step brothers/sisters)
- Marital Status should contain Married, Divorced, Widowed etc.
- Middle initials should be expanded

Date of Birth
Name Relationship Place of Birth Marital Status Present Address
D/M/Y

Father

Mother

Brother

Sister
10. DETAILS OF MEMBERSHIP WITH ANY ORGANIZATION (IF APPLICABLE)
PERIOD NAME OF TYPE OF POSITION CITY AND
(FROM AND TO) ORGANIZATION ORGANIZATION HELD/ACTIVITIES COUNTRY
MM/YYYY

11. IELTS OR CELPIP SCORES :

DATE OF TEST: mm/dd/yy
DATE OF TEST RESULTS: mm/dd/yy
READING:
WRITING:
LISTENING:
SPEAKING:

12. ECA (Education Credential Evaluation) report completed: If yes, please provide a scanned copy.
Yes or No :

13. Have you applied for ANY Canadian Visa before?: Yes or No:
If yes: please provide UCI#

14. Did you work or study in Canada at anytime?: Yes or No.

If yes: please contact your coordinator for further instruction

SUPPLEMENTARY INFORMATION
Your travels
List all trips You, Your spouse or common-law partner, Your dependent child 18 years old or older have taken
outside your country of origin or of residence in the last ten years (or since your 18th birthday if this was less than ten
years ago). Include all trips: tourism, business, training, etc. If you or your family member did not travel outside of
your country during this period, please mention as "did not travel".
Month-Year Month-Year Length Destination (City, Purpose of Travel
Country)
04-2004 04-2004 6 days Madrid, Spain Business