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Immigration Assessment Form

1 - Personal Information
Name:
Date of Birth :
Sex (Male/Female):
Contact Number:
Email:

2 - Family Composition
Present marital Status:
Number of Children with Age:

3 – Education

Duration (please
include the month and
year)

From

To

Academic &
Professional
Qualification

Marks

Name of School/University with

Obtained

country

4 - Work History
Total number of years of experience with complete history of past 10 years:
Duration(please
Name of the
include the month and
Designation and Job Profile
year)
Company
From
To

5 - Ability in Language – ENGLISH: (High/Moderate/Basic/None) Mention IELTS results
Reading

Writing

Speaking

Listening

SPEAKING:
LISTENING:
READING:
WRITING:

6 - Ability in Language – FRENCH: (High/Moderate/Basic/None)
Reading

Writing

Speaking

SPEAKING:
LISTENING:
READING:
WRITING:

Information on Spouse (Applicant’s Husband or Wife)
Name:
Date of Birth :
Sex (Male/Female):

Listening

7 – Education
Duration(please
include the month and
year)
From

To

Academic &
Professional
Qualification

Marks

Name of School/University with

Obtained

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(please include the
Name of the
month and year)
Designation and Job Profile
Company
From
To

11: Any self-employed profession by applicant or spouse during last 5 years?

PERSENT ADDRESS:Name of Office:

Protection of personal information
The personal information appearing on this form, and in any documents that must be appended to it, is required for
processing your application for Immigration to Canada, Act respecting immigration to Canada, the Regulation respecting the
selection of foreign nationals, the Regulation respecting the immigration consultants and their administrative regulations.
Your personal information is confidential and may not be disclosed without your consent unless explicitly authorized by you.
DECLARATION
I declare that the information contained in this application and appended documents, if any, is complete and accurate and I
will notify the representative of any change in answers given on this form before the submission of application to
Immigration Department (CIC), CANADA.
I acknowledge that I have read the notice on the protection of personal information in the section above.
I further acknowledge that by saving this document and sending the same to my legal representative electronically,
constitute my consent to use the information and no physical signature is required.
I also agree that Teraron Consulting will be making an initial assessment on the basis of the limited information provided on
this form.