Assessment Form

Preliminary Assessment Questionnaire
For Express Entry Permanent Residency / Temporary Residency

Web Form : Please fill up the web form below with complete details and submit it.

Applicant's First Name*

Middle Name (If applicable)

Last Name*

Date of Birth (dd/mm/yyyy)*

Place of Birth (Place, Country)*

Address Line 1*

Address Line 2

City*

Country*

Phone Number With Country and Area Code

Email*

Gender*

Marital Status*

Date of Marriage (dd/mm/yyyy) (If applicable)

Nationality*

Referred By

Principal Applicant: Write all your academic activities starting with most recent graduation.

Educational History*

Type of Graduation	Name of the University / College	From (mm/yyyy)	To (mm/yyyy)	Country

Principal Applicant: Write all your experience you have gained after your graduation.

Employment History

Company Name	Designation	From (mm/yyyy)	To (mm/yyyy)	Country

Principal Applicant: Language Test

Have you completed any languages test within past 2 years i.e. IELTS, CELPIP etc?

Yes
No
Not yet preparing for language exam

Module

Date of Test Result (MM/YYYY)

Are you willing to appear for exam?

Yes
No

When you are planning to appear for language test? (MM/YYYY)

Which language test you are planning to appear for?

When you are planning to appear for language test? (MM/YYYY)

Listening

Reading

Writing

Speaking

Overall Band

Do you have any Refusal / Rejection / Withdrawal of any applications for Canada or any other Country?
i.e. PR Application, Student, Visitor, Work Permit, etc. (If yes write full details below)

Do you have any Refusal / Rejection / Withdrawal of any applications for Canada or any other Country?*

Yes
No

Any Immigration Application Refusal History - If Applicable*

Country where Applied	Category for Applied	Date of Refusal

Are you currently living in Canada?
If yes, please provide details below.

Are you currently living in Canada?*

Yes
No

Residency Information - If Applicable*

Status in Canada	Permit Start Date	Permit Expiry Date

Have you ever lived in Canada previously ?*

Yes
No

Status in Canada	Permit Start Date	Permit Expiry Date

Do you have any relatives in Canada?
i.e. Parents, Grand Parents, Brother, sister, nephew, cousin, uncle, aunt. (If yes write full details below)

Do you have any relatives in Canada?*

Yes
No

In Canada Relative's Information - If Applicable*

Full Name of Relative in Canada	Address of Relative City / State name only	Relationship	Status of Relatives PR/Citizen

Spouse Information

Spouse First Name

Middle Name (If applicable)

Last Name

Any other Name used previously

Date of Birth (dd/mm/yyyy)

Place of Birth (Place, Country)

Full Mailing Address if different than Applicant's

Email

Cell Number with Country and Area Code

Spouse : Write all your academic activities starting with most recent graduation.

Educational History

Type of Graduation	Name of the University / College	From (mm/yyyy)	To (mm/yyyy)	Country

Spouse : Write all your experience you have gained after your graduation.

Employment History

Company Name	Designation	From (mm/yyyy)	To (mm/yyyy)	Country

Spouse : Language Test Result - if available

Have you completed any languages test within past 2 years i.e. IELTS, CELPIP etc?

Yes
No
Not yet preparing for language exam

Module

Date of Test Result (MM/YYYY)

Are you willing to appear for exam?

Yes
No

When you are planning to appear for language test? (MM/YYYY)

Which language test you are planning to appear for?

When you are planning to appear for language test? (MM/YYYY)

Listening

Reading

Writing

Speaking

Overall Band

Do you have any Refusal / Rejection / Withdrawal of any applications for Canada or any other Country?
i.e. PR Application, Student, Visitor, Work Permit, etc. (If yes write full details below)

Do you have any Refusal / Rejection / Withdrawal of any applications for Canada or any other Country?*

Yes
No

Any Immigration Application Refusal History - If Applicable*

Country where Applied	Category for Applied	Date of Refusal

Are you currently living in Canada?
If yes, please provide details below.

Are you currently living in Canada?*

Yes
No

Residency Information - If Applicable*

Status in Canada	Permit Start Date	Permit Expiry Date

Have you ever lived in Canada previously ?*

Yes
No

Status in Canada	Permit Start Date	Permit Expiry Date

Do you have any relatives in Canada?
i.e. Parents, Grand Parents, Brother, sister, nephew, cousin, uncle, aunt. (If yes write full details below)

Do you have any relatives in Canada?*

Yes
No

In Canada Relative's Information - If Applicable*

Full Name of Relative in Canada	Address of Relative City / State name only	Relationship	Status of Relatives PR/Citizen

Children Information

Do you have any children?*

Yes
No

Children Information*

Full Name	Date of Birth	Nationality	Gender

Travel Information (If you have travel outside of your origin country please write full details below)

Travel Information - If Applicable

Name of the Country	Status in Foriegn Country	From (dd-mm-yyyy)	To (dd-mm-yyyy)

You may provide additional information that you think would be relevant to your immigration assessment. Would you like to add information at this time?

Yes
No

Additional Information

"I understand that my first meeting with Unique International Immigration Services (UIIS) includes an initial brief free assessment of my circumstances to see if I qualify for making an application to Canada Immigration. Unique International Immigration will not accept clients who do not qualify. I will declare at the beginning of the meeting if I am here to discuss any matters that deal with an existing problem with Canada Immigration, an application that has already been submitted, to go into depth on my personal immigration circumstances, or an application which I intend to prepare and submit on my own, as these are NOT included in UIIS' free assessment, and I agree to pay for the entire consultation at UIIS' current hourly rate. I agree to provide complete and truthful information in the interview"

Preliminary Assessment Questionnaire
For Express Entry Permanent Residency / Temporary Residency

Principal Applicant: Write all your academic activities starting with most recent graduation.

Principal Applicant: Write all your experience you have gained after your graduation.