Dayana Immigration

Dayana Immigration Services

50156 RR 240 Leduc county, AB T4X0M4

www.dayanaimmigration.com

 info@dayanaimmigration.com 

Assesstment Form
Personal information
Please complete this form!

Consent to provide personal data.*

Consent to provide personal data.*

Your Name*

Your Name*

Your Last Name*

Your Last Name*

Date of Birth (day/month/year)*

Date of Birth (day/month/year)*

Sex (male/female)*

Sex (male/female)*

Country of Birth*

Country of Birth*

Country of Residence*

Country of Residence*

Passport Number

Passport Number

Country of Issue

Country of Issue

Date of Issue (day/month/year)

Date of Issue (day/month/year)

Date of Expiry (day/month/year)

Date of Expiry (day/month/year)

Current Address (Street, City, Province/State, Postal Code, Country)*

Current Address (Street, City, Province/State, Postal Code, Country)*

Cell Phone (including area code)*

Cell Phone (including area code)*

Home Phone (including area code)*

Home Phone (including area code)*

Email Address*

Email Address*

Are you married?*

Are you married?*

If you are married, what is the date
you were married? (day/month/year)

If you are married, what is the date
you were married? (day/month/year)

IF you are in a common-law relationship,
what was the date you started living
together? (day/month/year)

IF you are in a common-law relationship,
what was the date you started living
together? (day/month/year)

If you are married or in a common-law
relationship, is your partner Immigrating
to Canada with you? (Y/N)*

If you are married or in a common-law
relationship, is your partner Immigrating
to Canada with you? (Y/N)*

Do you have children? (Y/N)*

Do you have children? (Y/N)*

How many children do you have?*

How many children do you have?*

If you have children, include their ages below*

If you have children, include their ages below*

Indicate whether you have: worked
in/studied in/visited/never been to
Canada*

Indicate whether you have: worked
in/studied in/visited/never been to
Canada*

Have you ever had a work or study permit to
Canada? [Y/N)*

Have you ever had a work or study permit to
Canada? [Y/N)*

If you lived in Canada before, what were the dates?
(day/month/year)*

If you lived in Canada before, what were the dates?
(day/month/year)*

List the total amount of funds you have that are legal and transferrable (NOT include equity in real estate)*

List the total amount of funds you have that are legal and transferrable (NOT include equity in real estate)*

Do you or your partner have close family members who are permanent residents or citizens of Canada and live in Canada now? (Y/N)*

Do you or your partner have close family members who are permanent residents or citizens of Canada and live in Canada now? (Y/N)*

If you answered YES to the question to the left, please
state the relationship of the family member to you/your
partner and the name of the city in Canada in which
he/she resides.*

If you answered YES to the question to the left, please
state the relationship of the family member to you/your
partner and the name of the city in Canada in which
he/she resides.*

Education
Provide the following information for your high school and ALL schools attended thereafter, whether completed or not.

From (Year/month)*

From (Year/month)*

To (Year/month)*

To (Year/month)*

Name of school*

Name of school*

City/Country*

City/Country*

Type of Certificate or Diploma Issued *

Type of Certificate or Diploma Issued *

Area of Study--if not specific, write "General*

Area of Study--if not specific, write "General*

English Language Test
If you have taken an IELTS or CELPIP english language test, please complete the following!

IELTS or CELPIP*

IELTS or CELPIP*

Date of Test (day/month/year)*

Date of Test (day/month/year)*

General or Academic*

General or Academic*

Ability Category Results (Reading, Writing, Listening, Speaking)*

Ability Category Results (Reading, Writing, Listening, Speaking)*

Employment history
Please provide your employment history for the past ten (10) years-beginning with current-and include part-time positions!

From (year/month) *

From (year/month) *

To (year/month) *

To (year/month) *

Job title*

Job title*

City or Town, and Country*

City or Town, and Country*

Name of Company, Employers, School
*

Name of Company, Employers, School
*

Street Address of CANADIAN
Employers ONLY

*

Street Address of CANADIAN
Employers ONLY

*

Travel
Please list all international travel in the last ten (10) years!

City and Country*

City and Country*

Purpose of trip*

Purpose of trip*

From (year/month)*

From (year/month)*

To (year/month)*

To (year/month)*

Visa issued Y/N*

Visa issued Y/N*

Additional Question
Read the following carefully and answer truthfully. Have you or your spouse/partner or dependents ever! Answer NO or YES (Provide a detailed explanation in the space below)

Been convicted of, or currently subject to any criminal proceeding in any county?*

Been convicted of, or currently subject to any criminal proceeding in any county?*

Previously sought refugee status in Canada or applied for Canadian immigrant or permanent resident visa OR any other type of visa (temporary resident or visitor)?*

Previously sought refugee status in Canada or applied for Canadian immigrant or permanent resident visa OR any other type of visa (temporary resident or visitor)?*

Been denied refugee status, OR any type of visa ( immigrant, permanent resident, visitor, temporary resident) in Canada or any other country?*

Been denied refugee status, OR any type of visa ( immigrant, permanent resident, visitor, temporary resident) in Canada or any other country?*

Been refused admission to or ordered to leave Canada OR any other country?*

Been refused admission to or ordered to leave Canada OR any other country?*

Been involved in an act of genocide, a war crime, a crime against humanity, or the desecration of religious property?*

Been involved in an act of genocide, a war crime, a crime against humanity, or the desecration of religious property?*

Used, use or plan to use violence as an end to achieve political, social or religious objectives?*

Used, use or plan to use violence as an end to achieve political, social or religious objectives?*

Been a member of a group that is or was involved with organized crime?*

Been a member of a group that is or was involved with organized crime?*

Had any serious diseases or physical or mental disorders?*

Had any serious diseases or physical or mental disorders?*

Is there any other information that you feel is important to share as part of your preliminary assessment?

Is there any other information that you feel is important to share as part of your preliminary assessment?