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ECONOMIC CLASSES
ATLANTIC IMMIGRATION PILOT PROGRAM

All Atlantic Immigration Pilot Program principal applicants must complete this form.

1. Your full name 3. Which Atlantic provincial government has endorsed you?

Family name Domingo New Brunswick

Given name(s) Jyselle Elyssa 4. Which Atlantic Immigration program are you applying under?
✔ Atlantic High-Skilled Program
Given name(s)
Atlantic Intermediate-Skilled Program
Atlantic International Graduate Program

2. Your date of birth 5. Funds

Date Amount of unencumbered transferable and

(YYYY-MM-DD)
1985-01-26 $ 7,000.00
available funds you have, in Canadian dollars

Declaration

I declare that my family members and I intend to live in the Atlantic Province that endorsed me.

I authorize the Government of Canada to share all necessary information respecting my application for permanent residence in Canada, including the
status to the application decision, with officials of the provincial government that endorsed me.

Signature

Date
(YYYY-MM-DD)

This form is made available by Citizenship and Immigration Canada and is not to be sold to applicants.
IMM 5501 (03-2017) E (DISPONIBLE EN FRANÇAIS - IMM 5501 F)