CANIMM Intake Form - Lawseph & Associates

Immigration Intake Form

Step 1 of 9

Name

First

Last

UCI

If known to the client. This is the Universal Client Identifier used by IRCC.

Program Applying *

Typically, the applicant will select a main category of Family, Economic, Refugee, or Other and then select a subcategory for that parent category below.

Birth Previously Refused

Family Class

Economic

Refugee

Other

Sex

Date of Birth

Eye Color *

Height

indicate if in cm, ft, or in.

Program Applying

What type of immigration application are you applying for?

How many family members

This number includes you in this application.

Language Correspondence

English
French
Mixed Hybrid

In which language do you wish to be contacted by?

Target Province *

City / Town

Interpreter Requested

Certificate Selection Quebec (CSQ)

Have you received your Certificate de Selection du Quebec (CSQ)

CSQ Number

CSQ Date Applied

Ever gone by a nickname, alias, maiden name etc.

Used any other name? (e.g. Nickname, maiden name, alias, etc.)

Nickname 01

Nickname 02

Country of Residence *

What is the country that you are currently residing in?

IMM Status*

Issue Date

The date you obtained your IMM status.

Expiry Date

The date that your IMM status will expire.

Birth Country *

City of Birth

Citizenship Country #1

This country of citizenship does not include your origin of birth.

Citizenship Country #2

Canada Entry Date

Date and place of your last entry to Canada

Entry Place

Date and place of your last entry to Canada

Arrival Date

Previous country that you lived in since you turned 18 and for more than a duration of 6 months.

Departure Date

Previous country that you lived in sicne you turned 18 and for more than a duration of 6 months.

IMM Status

Country

This country of citizenship does not include your origin of birth.

Arrival Date

Previous country that you lived in since you turned 18 and for more than a duration of 6 months.

Departure Date

Previous country that you lived in since you turned 18 and for more than a duration of 6 months.

IMM Status

Country

This country of citizenship does not include your origin of birth.

Marital Status *

Marriage Date

Partner Name

Previously Married

Partner Name

Relationship Start

Start of the relationship, union, common-law, or full marital.

Relationship End

End of the relationship.

Date of Birth

Relationship Type

Move In Date

When you first started living at the indicated residential address.

Move Out Date

The the end or present date of you living at the indicated residential address.

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Ownership Type

Additional Addresses

Telephone Number

Canada / U.S.A
Other

Type*

Country Code

Phone Number

Telephone Number

Canada / U.S.A
Other

Type

Country Code

Phone Number

Extension

Passport / Travel Document?

Do you have a valid passport / travel document?

Passport Number

Issue Date

Expiry Date

Alternate Country

This country of citizenship does not include your origin of birth.

Alternate Passports

Taiwan
Israeli
National Identity Document
USPR Card

NAT Document Number

Issue Date

Expiry Date

USPR Card Document Number

Are you a lawful permanent resident of the U.S. with a valid green card?

Issue Date

Expiry Date

Highest Education*

Education Years Total

Number of years of education in total

Current Occupation

Intended Occupation

Native Language

Native Language / Mother Tongue

Able Communication*

Language Preference*

Designated Language Test

Have you taken a test from a designated testing agency to assess your proficiency in English or French?

Test Type

Language Test Version

Language Test version (eg. General)

Language Test Date

Date of Language Test

Test Results Date

Date of Test Results

Test Type

Language Test Version

Language Test version (eg. General)

Language Test Date

Date of Language Test

Test Results Date

Date of Test Results

Speaking

Reading

Listening

Writing

Overal Score

Mothers Name

Date of Birth

Country of Birth*

This country of citizenship does not include your origin of birth.

Address

If desceased, write date and place of death. Sorry for your loss.

Marital Status *

Fathers Name

Date of Birth

Country of Birth*

This country of citizenship does not include your origin of birth.

Address

If desceased, write date and place of death. Sorry for your loss.

Marital Status *

Sibling 01 Name

Date of Birth

Country of Birth

This country of citizenship does not include your origin of birth.

Address

If desceased, write date and place of death. Sorry for your loss.

Marital Status

Sibling 02 Name

Date of Birth

Country of Birth

This country of citizenship does not include your origin of birth.

Address

If desceased, write date and place of death. Sorry for your loss.

Marital Status

Sibling 03 Name

Date of Birth

Country of Birth

This country of citizenship does not include your origin of birth.

Address

If desceased, write date and place of death. Sorry for your loss.

Marital Status

Sibling 04 Name

Date of Birth

Country of Birth

This country of citizenship does not include your origin of birth.

Address

If desceased, write date and place of death. Sorry for your loss.

Marital Status

Children 01 Name

Date of Birth

Country of Birth

This country of citizenship does not include your origin of birth.

Address

If desceased, write date and place of death. Sorry for your loss.

Marital Status

Children 02 Name

Date of Birth

Country of Birth

This country of citizenship does not include your origin of birth.

Address

If desceased, write date and place of death. Sorry for your loss.

Marital Status

Children 03 Name

Date of Birth

Country of Birth

This country of citizenship does not include your origin of birth.

Address

If desceased, write date and place of death. Sorry for your loss.

Marital Status

Visiting Person #1

Date of Birth

Country of Birth

This country of citizenship does not include your origin of birth.

Address

If desceased, write date and place of death. Sorry for your loss.

Visiting Person #2

Date of Birth

Country of Birth

This country of citizenship does not include your origin of birth.

Address

If desceased, write date and place of death. Sorry for your loss.

Financial Supporter #1

Date of Birth

Country of Birth

This country of citizenship does not include your origin of birth.

Address

If desceased, write date and place of death. Sorry for your loss.

Financial Supporter #1

Date of Birth

Country of Birth

This country of citizenship does not include your origin of birth.

Address

If desceased, write date and place of death. Sorry for your loss.

Program Start

Program Completion

Institution Name

Award Type

Program Start

Program Completion

Institution Name

Award Type

Program Start

Program Completion

Institution Name

Award Type

Employment Start

Employment End

Employer Name

Country

This country of citizenship does not include your origin of birth.

Employment Start

Employment End

Employer Name

Country

This country of citizenship does not include your origin of birth.

Employment Start

Employment End

Employer Name

Country

This country of citizenship does not include your origin of birth.