Initial Intake Form Name * First Name Last Name Age * Country of Residence * Preferred Destination In Canada * Do you have any children under the age of 19? Yes No Marital Status * Single Married Common Law Partner English Writing Expert Very Good Competent Limited Not at all Reading Expert Very Good Competent Limited Not at all Speaking Expert Very Good Competent Limited Not at all Listening Expert Very Good Competent Limited Not at all French Writing Expert Very Good Competent Limited Not at all Reading Expert Very Good Competent Limited Not at all Speaking Expert Very Good Competent Limited Not at all Listening Expert Very Good Competent Limited Not at all Have you completed high school (secondary school)? Yes No Type of Degree Less than Secondary/ Highschool Secondary/Highschool College Diploma Bachelors Degree Post Graduate Degree Masters Degree Doctorate / PHD Name of Educational Institution Field of Study Program Start Date Program End Date Country of Study City of Study Name of Company or Organization Employment History Job Title Start Date End Date Employment Status Full Time Part Time Third Choice Number of hours worked per week Employment Duties Address Country Have you already submitted an Express Entry profile to the Government of Canada within the past 12 months? Yes No Do you have friends or relatives residing in Canada? Yes No Do you currently have an offer of employment from a Canadian Employer? Yes No Have you (or your spouse or common-law partner or any of your dependent children) ever had a criminal record? Yes No Have you taken an English or French test? English (CELPIP) General Test Englilsh (IELTS) General Training test French (TEF) Canada French (TCF) Canada Do you have any family members or relatives living in Canada and who are 18 years or older? Yes No Have you or (your spouse, common-law partner, or any dependent children) ever had a serious medical condition? Yes No Have you or your spouse previously applied for a visa to Canada? Yes No Personal Net Worth (CAD$)* * Additional Comments Email* * Phone Number* * Thank you!
