IMMIGRANT ASSESSMENT FORM

1 - Personal Information
Full Name: Date Of Birth: Sex (Male/Female): Contact Number: Email: Current Address: DOMINIC JARDELEZA JUNE 10,1985 MALE 09206964326 durk_122002@yahoo.com BLK 11 LOT 1&3 IMPERIAL 6 SUBD. MANDURRIAO, ILOILO CITY

2 - Family Composition
Present Marital Status: Number Of Children With Age: SINGLE NONE

3 Education
Duration From (Month -Year)
June 2002

To (Month -Year)
October 2006

Academic & Professional Qualification

Bachelor of Science In Nursing

Passed/Undergrad/Ongoing
Passed

Name Of School/University With Country

University of San Agustin

4 - Work History
Total Number Of Years Of Experience With Complete History Of Past 10 Years: Duration Name Of The From To Company, Designation And Job Profile (Month(Month Country Year) -Year) December present Western Staff Nurse 2007 Visayas Medical Center

5 - Ability In Language ENGLISH: (High/Moderate/Basic/None) Mention IELTS Results

SPEAKING: LISTENING: READING: WRITING: 6 6 5 6

6 - Ability In Language FRENCH: (High/Moderate/Basic/None)

SPEAKING: LISTENING: READING: WRITING: NONE NONE NONE NONE

Information On Spouse (Applicants Husband Or Wife)

Full Name: Date Of Birth : Contact Number: Email: Current Address:

7 Education
Duration From (Month -Year) To (Month -Year) Academic & Professional Qualification Passed/Undergrad/Ongoing Name Of School/University With Country

8- Ability In Language ENGLISH: (High/Moderate/Basic/None) Mention IELTS Results

SPEAKING: LISTENING: READING: WRITING:

9 - Ability In Language FRENCH: (High/Moderate/Basic/None)

SPEAKING: LISTENING: READING: WRITING:

10 - Work History Of Spouse

Total Number Of Years Of Experience With Complete History Of Past 10 Years: Duration Name Of The From To Designation And Job Profile Company (Month (Month -Year) -Year)

11: Any Self-Employed Profession By Applicant Or Spouse During Last 5 Years? Korean tutor

Signature Of Staff: Ben Ryan \ Ralph \ Cris \ Leah \ Adrianne Name Of Office: Wideworld International Services, Inc. (Wise, INC.)