If you would like more information on your eligibility to apply under the Family Class, please complete this form. PERSONAL INFORMATION Name: Email Address: Nationality: Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda S. Georgia and S. Sandwich Islands Saint Kitts and Nevis Saint Lucia Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea Soviet Union Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay US Minor Outlying Islands US Virgin Islands Uzbekistan Vanuatu Venezuela Viet Nam Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe Current Place of Residence: include city and country Daytime Phone: include area code Date of Birth: Select Date Sex: - Male Female Marital Status: - Single Married/Common Law Divorced/Separated Number of Dependant Children: If you are married, please provide your spouse's details Spouse's date of birth: Select Date Spouse's Education: - Diploma/Certificate Bachelors Degree Masters Degree Doctorate High School/Secondary School Other None Spouse's total years of education: Starting from Primary Spouse's field of study: Spouse's Number of Years and Months of Working Experience : YOUR ABILITY IN ENGLISH AND FRENCH English Read: - High Moderate Poor None Write: - High Moderate Poor None Speak: - High Moderate Poor None Listen: - High Moderate Poor None French Read: - High Moderate Poor None Write: - High Moderate Poor None Speak: - High Moderate Poor None Listen: - High Moderate Poor None Please specify the Assessment Questionnaire you are applying for: - Skilled Workers Business Class Canada Experience Class Nova Scotia Provincial Nominee Programme Please inform us how you were introduced to this site: - Search Engine Newspaper or Magazine Newsgroup General Recommendation Please specify: Additional comments if any:

Speak With a Lawyer Jennifer Ross Morgan Hicks Jason May   Contact Us 1-866-429-4111 wh@wickwireholm.com