Humanitarian & Compassionate

Dear customer, by filling out this form we will be able to carry out your process efficiently, this information will be used exclusively for your application. It is necessary that you answer all questions honestly and completely, as this is information reviewed by the Government of Canada. If the question does not apply to your process, please write “N/A”.

Personal Information

Applicant Full Name*Email*Have you ever used any other name (e.g. nickname, maiden, alias, etc.? *Other nameSex*
Height ("cm" or "ft/in") *Eye Colour*Date of birth*Place of birth (City/Town)*Country of birth*Provide your citizenship*Current country or territory of residence*Current occupation*

Personal Information II

Date of your last entry to Canada*Place of your last entry to Canada (City and airport)*How many family members, including you, are in this application?*Is someone in your family members in the application younger than 19 years?*Where do you intend to live in Canada (Provide province and city)*

Marital Status

Marital status*
Date on which you were married or entered into the relationship
Full Family Name(s) of your current Spouse/Common-law partner
Full Given Name(s) of your current Spouse/Common-law partner
Have you previously been married or in a common-law partner?*
Full Name(s) of your previous Spouse/Common-law partner
Type of relationshipDate of birth of your previous Spouse/Common-law partnerRelationship start dateRelationship finish date

Address Contact

Full address*
Street No.*
Apt/Unit*
City/Town*
Country or Territory*
Province/State*
Postal Code*

Telephone number with country code*

Type of telephone*

If you have an alternative phone number, provide it with the country code

Alternative telephone-type

Document

Passport number*Upload a clear and complete passport image (without shadows)*

Upload File

Max file size 10MB.

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Passport country of territory issue*Passport Issue date*Passport Expire date*For this trip, will you use a passport issued by the Ministry of Foreign Affairs in Taiwan that includes your personal identification number?*For this trip, will you use a National Israeli passport?*Do you have a national identity document?*Upload a clear and complete National identity document image (without shadows)*

Upload File

Max file size 10MB.

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Document number*Country or territory of issue*Issue date*Expiry date *

Education Employment

Number of years of elementary school successfully completed*
Number of years of secondary school successfully completed*
Number of years of University school successfully completedNumber of years of other post secondary school successfully completedHighest level of education*Date your highest educational credential was obtained*SECONDARY SCHOOL*Full address of institution*From*To*City and country*Type of certificate or diploma issued*Field of study*

Education Employment II

Post Secondary
Full address of institution
From*To*City and country*Type of certificate or diploma issued*Field of study*Currently Job title*NocWhat is your most recent hourly wage?*Since when did you start earning the salary mentioned in the previous question?*Please confirm your first day in the company under payroll, (Employment start date is not always the same as Work Permit approval date)

Language

Language preference for correspondence:*Language preference for Interview:*Interpreter requested:*Are you able to communicate in English and / or French?*
Native language/Mother Tongue / Lengua materna:*
Have you taken a test from a designated testing agency to asses your proficiency in English or French?*
Which language test did you take for your first official language?
Date Of Test
Test results: Speaking
Listening
Writing
Reading

Association

MEMBERSHIP OF ASSOCIATION WITH ORGANIZATIONSWhat organizations have you supported, been a member of or been associated with? Include any political, social, youth or student organization, trade unions and professional associations. Do not use abbreviations. Indicate the city and country or territory where you were a member

1. From ___________________________________________

Name of organization

Type of organization

Activities or position

City and country

2. From ___________________________________________

Name of organization

Type of organization

Activities or position

City and country

3. From ___________________________________________

Name of organization

Type of organization

Activities or position

City and country

Association II

GOVERNMENT POSITIONSList any government positions (such as civil servant, judge, police officer, or employee in a security organization) you have held. Include positions you have held before or after your retirement. Do not use abbreviations.

1. From ___________________________________________

Country/Territory and level of jurisdiction

Department/Branch

Activities and/or positions held

2. From ___________________________________________

Country/Territory and level of jurisdiction

Department/Branch

Activities and/or positions held

3. From ___________________________________________

Country/Territory and level of jurisdiction

Department/Branch

Activities and/or positions held

Past Years

PRINCIPAL APPLICANT INFORMATIONList all the addresses where you have lived since your 18 birthday or the past 10 years whichever is most recent; Specify the exact dates and address in the continue gaps:

1. From* ______________________

To*

City/town and Province*

Country and Postal Code*

Street and number*

2. From* ______________________

To*

City/town and Province*

Country and Postal Code*

Street and number*

3. From ______________________

City/town and Province

Country and Postal Code

Street and number

4. From ______________________

City/town and Province

Country and Postal Code

Street and number

5. From ______________________

City/town and Province

Country and Postal Code

Street and number

6. From ______________________

City/town and Province

Country and Postal Code

Street and number

Past Years II

PRINCIPAL APPLICANT INFORMATIONList all the trips you, and if applicable your family member have taken outside of your country of origin or residence since your 18 birthday or the past 10 years whichever is most recent; including tourism, travel and training:

1. From ______________________

Duration of trip in days

Destination (City/Country)

Purpose of travel

2. From ______________________

Duration of trip in days

Destination (City/Country)

Purpose of travel

3. From ______________________

Duration of trip in days

Destination (City/Country)

Purpose of travel

4. From ______________________

Duration of trip in days

Destination (City/Country)

Purpose of travel

5. From ______________________

Duration of trip in days

Destination (City/Country)

Purpose of travel

Applicant Activity

PRINCIPAL APPLICANT INFORMATION

Proved information about your story since age 18 or in the past 10 years, whichever is most recent. Under activity, write your occupation or job title if you were working; if you were not working, provide the information that you were doing (Unemployment, studying, travelling, retired, detention, etc.):

1. From* ______________________

To*

Activity*

City/town and Country*

Status in the Country*

Name of the company, employer or school*

Length*

2. From* ______________________

To*

Activity*

City/town and Country*

Status in the Country*

Name of the company, employer or school*

Length*

3. From ______________________

Activity

City/town and Country

Status in the Country

Name of the company, employer or school

Length

Applicant Activity II

Please write “N/A”, if not applicable to you

4. From* ______________________

To*

Activity*

City/town and Country*

Status in the Country*

Name of the company, employer or school*

Length*

5. From ______________________

Activity

City/town and Country

Status in the Country

Name of the company, employer or school

Length

6. From ______________________

Activity

City/town and Country

Status in the Country

Name of the company, employer or school

Length

Applicant Activity III

Please write “N/A”, if not applicable to you

7. From* ______________________

To*

Activity*

City/town and Country*

Status in the Country*

Name of the company, employer or school*

Length*

8. From ______________________

Activity

City/town and Country

Status in the Country

Name of the company, employer or school

Length

9. From ______________________

Activity

City/town and Country

Status in the Country

Name of the company, employer or school

Length

Applicant Activity IV

Please write “N/A”, if not applicable to you

10. From* ______________________

To*

Activity*

City/town and Country*

Status in the Country*

Name of the company, employer or school*

Length*

Background Disclaimer

Have you or, any of your family members listed in this application, ever been convicted of a crime or offence in Canada for which a pardon has not been granted under the Criminal Records Act of Canada*:

Have you or, any of your family members listed in this application, ever been convicted of or are currently charged with, on trial for, or party to a crime or offence, or subject of any criminal proceedings in any other country or territory?*:

Have you or, any of your family members listed in this application, ever made previous claims for refugee protection in Canada or at a Canadian visa office abroad, in any other country(ies) or territory(ies), or with the United Nations High Commissioner for Refugees (UNHCR)?*:

Background Disclaimer II

Have you or, any of your family members listed in this application, ever been refused refugee status, an immigrant or permanent resident visa (including a Certificat de Sélection du Québec [CSQ] or application to the Provincial Nominee Program) or a visitor or temporary resident visa, for Canada or any other country or territory?*:

Have you or, any of your family members listed in this application, ever been refused admission to, or ordered to leave, Canada or any other country or territory?*:

Have you or, any of your family members listed in this application, ever been involved in an act of genocide, in a war crime or in the commission of a crime against humanity?*:

Have you or, any of your family members listed in this application, ever used, planned or advocated the use of armed struggle or violence to reach political, religious or social objectives?*:

Background Disclaimer III

Have you or, any of your family members listed in this application, ever been associated with a group that used, uses, or advocated or advocates the use of armed struggle or violence to reach political, religious or social objectives?*:

Have you or, any of your family members listed in this application, ever been a member of an organization that is or was engaged in an activity that is part of a pattern of criminal activity?*:

Have you or, any of your family members listed in this application, ever been detained, incarcerated or put in jail?*:

Have you or, any of your family members listed in this application, ever had any serious disease or physical or mental disorder?*:

Consent

I declare that I have answered all questions in this application fully and truthfully*
I certify that the information contained in this document is complete, accurate and factual. I also realize that once this document has been completed and signed that it will form part of my Immigration Record and will be used to verify my family details on future applications*
I accept that Rita Khalfon Immigration Consulting makes use of my information for my immigration application process*

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