WORK Asterisk * is mandatory. Did you ever get a CAQ?* No Yes Have you been refused a work permit?* No Yes PERSONAL DETAILS 1.Full name 2.Have you ever used any other name(e.g. Nickname, maiden name, alias, etc)?* No Yes please provide the name Family name Given name 3.Sex* Female Male Unkown Another gender 4.Date of birth 5.Place of birth 6.Citizenship 7.Current country or territory of residence: Status Citizen Permanent resident Visitor Worker Student Other Protected Person Refugee Claimant 8.Previous countries or territories of residence:During the past five years, have you lived in any country or territory other than your country of citizenship or your current country or territory of resedence(indicated above) for more than six month? No Yes please provide details Status Visitor Citizen Permanent resident Worker Student Other Protected Person Refuge Claimant Foreign National From To The second country The second country Status Visitor Citizen Permanent resident Worker Student Other Protected Person Refuge Claimant Foreign National From To 9.Your current marital status Annulled Marriage Common-Law Divorced Legally Separated Married Single Unkown widower Provide the date on which you were married or entered into the common-law relationship Provide the name of your current Spouse/Common-law parther Is your spouse or common-law partner a Canadian citizen or permanent resident? No Yes 10.Have you previously been married or in a common-law relationship? No Yes Provide the following details for your previous Spouse/Common-law partner: Type of relationship common-law married From To Date of birth 11. In the past 10 years, have you given your fingerprints and photo (biometrics) for an application to come to Canada? No Yes LANGUAGE(S) a) Native language/Mother Tongue b) Are you able to communicate in English or French? English French Both Neither c) In which language are you most at ease? English French d) Have you taken a test from a designated testing agency to assess your proficiency in English or French? No Yes NATIONAL IDENTITY DOCUMENT 1.Do you have a national identity document? No Yes 2.Document number 3.Country or territory of issue 4.Issue date 5.Expiry date US PR CARD 1.Are you a lawful Permanent Resident of the United States with a valid alien registration card (green card)? No Yes 2.Document number 3.Expiry date CONTACT INFORMATION 1.Current Residential address 2.Telephone no. Canada/Us Other 3.E-mail address COMING INTO CANADA 1.Date and place of your original entry to Canada (your first entry to Canada) Date 2.The original purpose for coming to Canada Business Tourism Study Work Other Family Visit Name of person visited Address Phone Relationship 3.Date and place of your most recent entry to Canada (if not the same as original entry) Date DETAILS OF INTENDED WORK IN CANADA 2.Details of my prospective employer(attach original offer of employment) a.Name of Employer(if you are employed by a foreign employer who has been awarded a contract to provide services to a Canadian entity, please identify the foreign employer here) b.Complete Address of Employer(Canadian or Foreign) 3.Intended location of employment in Canada? 4.My occupation in Canada will be: 5.Duration of expected employment: From To 7.If you have been issued a CAQ, provide the: Exipry date 8.Have you been issued a certificat under the provincial Nominee program?: No Yes EDUCATION Have you had any post secondary education (including university, college or apprenticeship training)*? No Yes 1.Give full details of your highest level of post secondary education From To EMPLOYMENT Give details of your employment for the past 10 years, including if you have held any government position (such as civil servant, judge, police officer, mayor, member of parliament, hospital administration)* 1. From* To* Second employment 2. From To Third employment 3. From To BACKGROUND INFORMATION You must complete this section if you are 18 years of age or older 1.a)Within the past two years, have you or a family member ever had tuberculosis of the lungs or been in close contact with a person with tuberculosis* No Yes 1.b)Do you have any physical or mental disorder that would require social and/or health services, other than medication, during a stay in Canada? No Yes 2.a)Have you ever remained beyond the validity of your status, attended school without authorization or worked without authorization in Canada? No Yes 2.b)Have you ever been refused a visa or permit, denied entry or ordered to leave Canada or any other country or territory? No Yes 2.c)Have you previously applied to enter or remain in Canada? No Yes 3.a)Have you ever committed, been arrested for or been charged with or convicted of any criminal offence in any country or territory? No Yes 4.a)Did you serve in any military, militia, or civil defence unit or serve in a security organization or police force(including non obligatory national service, reserve or volunteer units)? No Yes 5.Are you or have you ever been a member or associated with any political party,or other group or organization which has engaged in or advocated violence as a means to achieving a political or religious objective, or which has been associated with criminal activity at any time? No Yes 6.)Have you ever witnessed or participated in the ill treatment of prisoners or civilians, looting or desecration of religious building? No Yes ACCOMPANY PERSONS Are there persons in your immediate family (Parents/children) who are already in Québec or who will accompany you during your entire period of study? No Yes Entre the information respecting each of these persons and specify what is or will be the reason for this person’s presence in Québec.Note: A separate application for a temporary selection of studies must be completed for each family member who will be studying in Québec, unless this person is exempt Click ‘ADD’ button and write the personal details.
