Express Entry Free Assessment Form

Name:

Email:

Nationality:

Current Place of Residence: (City, Country)

Daytime Telephone number:

Date of Birth: (DD, MM, YYYY)

Gender:

Male

Female

Marital Status:

Single

Married

Divorced/Separated

Widowed

Spouse's Date of Birth: (DD, MM, YYYY)

Spouse's Highest Level of Education:

Spouse's Field of Study:

Spouse's Number of Years & Months of Work Experience:

Spouse's French Language Ability:

Number of Dependant Children:

Your Own English Language Skills:

Your Own French Language Skills:

Total Number of Years of Education:

First Certificate Acquired:

Field of Study:

Name of Institution:

City, Country:

2nd Certificate Acquired:

Field of Study:

Name of Institution:

City, Country:

3rd Certificate Acquired:

Field of Study:

Name of Institution:

City, Country:

Employment History: 1st Company or Organization Name:

Job Title

From Date: (DD, MM, YYYY)

To Date: (DD, MM, YYYY)

Employment Status:

Full Time

Part Time

Number of Hours Worked per Week:

Do You Still Work at This Company?

Employment Duties:

City, Country:

2nd Company or Organization Name:

Job Title:

From Date: (DD, MM, YYYY)

To Date: (DD, MM, YYYY)

Employment Status:

Full Time

Part Time

Number of Hours Worked per Week:

Do You Still Work at This Company?

Employment Duties:

City, Country:

3rd Company or Organization Name:

Job Title:

From Date: (DD, MM, YYYY)

To Date: (DD, MM, YYYY)

Employment Status:

Full Time

Part Time

Number of Hours Worked per Week:

Do You Still Work at This Company?

Employment Duties:

City, Country:

Relationship to Closest Blood Relative in Canada (Canadian Citizen or Landed Immigrant):

Blood Parent

Blood Aunt or Uncle

Blood Brother or Sister

Blood Son or Daughter

Blood Niece or Nephew (22 Years or Older)

Blood Grand Parent

Blood Cousin

Relative's Province of Residence:

Personal Net Worth (in Canadian Dollars):

Do you currently have an offer of employment from a Canadian employer?

Yes

If Yes, Provide Details Here:

Have you or your spouse/common law partner or dependent children ever have any serious disease?

Yes

Have you or your spouse/common law partner or dependent children ever been convicted of or currently charged with any crime or offence in any country?

Yes

Have you or your spouse/common law partner or dependent children ever applied for an immigrant visa to Canada?

Yes

Have you or your spouse/common law partner or dependent children ever visited Canada (for a visit, study or work)?

Yes

If The Answer to Any of The Above Four Questions Is Yes, Provide Details Below:

Additional Comments if Any:

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