Student Questionnaire

Personal Information

First Name

Last Name

Date of Birth

First Language

Country of Citizenship

Passport number

Gender

Address Detail

Address

City

Country

State/Province

Postal/Pin code

Email

Phone number
Education Details

Country of Education

Highest level of Education

Name of the institution

Percentage and GPA

Did you complete your study or any

backlogs?
Any gap in Education? If yes please
explain

Background Immigration information

Any Visa Refusal? Yes or No

If yes, please provide detail such as

Refusal date, type of visa.

By signing this, I confirm that the information given in this form is

true, complete and accurate.

Applicant/Client’s Signature: _____________________

Date: __________

Alcan Visa Services Representative’s Initials: ____________

Date: ______________