Owner/Operator and Startup Free Assessment

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 Total Years of Education:

Spouse's Field of Study:

Spouse's Number of Years and Months of Working Experience:

Spouse's French Language Ability:

Number of Dependent Children:

Your Own English Language Skills:

Your Own French Language Skills:

Total Years of Education:

1st Certificate:

Field of Study:

Month And Year Started:

Month And Year Ended:

Name of Institution:

City And Country:

2nd Certificate:

Field of Study:

Month And Year Started:

Month And Year Ended:

Name of Institution:

City And Country:

3rd Certificate:

Field of Study:

Month And Year Started:

Month And Year Ended:

Name of Institution:

City And Country:

Managerial Experience; Name of Company or Organization (1):

Job Title:

From Month & Year:

To Month & Year:

Employment Status:

Full Time

Part Time

Number of Hours Worked per Week:

Do You Presently Work at This Company?

Yes

Employment Duties:

City, Country:

Managerial Experience; Name of Company or Organization (2):

Job Title:

From Month & Year:

To Month & Year:

Employment Status:

Full Time

Part Time

Number of Hours Worked per Week:

Do You Presently Work at This Company?

Yes

Employment Duties:

City, Country:

Managerial Experience; Name of Company or Organization (3):

Job Title:

From Month & Year:

To Month & Year:

Employment Status:

Full Time

Part Time

Number of Hours Worked per Week:

Do You Presently Work at This Company?

Yes

Employment Duties:

City, Country:

Most Recent Business Owned Name (1):

Type of Business Activity:

Type of Ownership:

Proprietorship

Partnership

Corporation

Percentage of Ownership:

From Month, Year:

To Month, Year:

Annual Sales in Canadian Dollars:

Net Income in Canadian Dollars:

Net Assets in Canadian Dollars:

Number of Full Time Employees:

Previous Year's Business Owned Name (2):

Type of Business Activity:

Type of Ownership:

Proprietorship

Partnership

Corporation

Percentage of Ownership:

From Month, Year:

To Month, Year:

Annual Sales in Canadian Dollars:

Net Income in Canadian Dollars:

Net Assets in Canadian Dollars:

Number of Full Time Employees:

Previous Year's Business Owned Name (3):

Type of Business Activity:

Type of Ownership:

Proprietorship

Partnership

Corporation

Percentage of Ownership:

From Month, Year:

To Month, Year:

Annual Sales in Canadian Dollars:

Net Income in Canadian Dollars:

Net Assets in Canadian Dollars:

Number of Full Time Employees:

Previous Year's Business Owned Name (4):

Type of Business Activity:

Type of Ownership:

Proprietorship

Partnership

Corporation

Percentage of Ownership:

From Month, Year:

To Month, Year:

Annual Sales in Canadian Dollars:

Net Income in Canadian Dollars:

Net Assets in Canadian Dollars:

Number of Full Time Employees:

Previous Year's Business Owned Name (5):

Type of Business Activity:

Type of Ownership:

Proprietorship

Partnership

Corporation

Percentage of Ownership:

From Month, Year:

To Month, Year:

Annual Sales in Canadian Dollars:

Net Income in Canadian Dollars:

Net Assets in Canadian Dollars:

Number of Full Time Employees:

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 Parents

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 Answer Is Yes Provide Details Below:

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

Yes

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

Yes

Have you or 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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