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——————————————————– Canadian Education total number of years: Canadian Work Exp. Total number of years: NOC Code qualifies: Language: English French Pass Fail Will qualify in future: Conditional on: ——————————————————– 
Canadian Experience Class Assessment

Please complete this brief confidential form in full in English or French. Only fully completed forms will be reviewed, assessed, and replied to.

Contact Information

Given name(s)
Surname (Family name(s))
Date of birth (day/month/year)

Telephone Number
Cell Number
Work Number
E-mail address
Alternate e-mail address

Address in Canada

Marital Status
Children
Age of Children
Nationality (citizenship)
How did you hear of us?

Canadian Education

Canadian Education completed: Please list only full-time completed studies taken in Canada. Please do not list studies outside of Canada in this section.

Name of Degree or Certification
Name of School
Did you graduate?
Graduation date

Name of Degree or Certification
Name of School
Did you graduate:
Graduation date

Total number of years of full time studies in Canada

Do you have a post-graduate work permit
If yes, for how many years
Permit expiry date

Canadian Employment History

Please list only companies you have worked for in Canada that was not part of a student coop placement.
Job Title
Length of Employment	years	months
Company
Valid Work Permit during employment?
Main duties of job

Job Title
Length of Employment	years	months
Company
Valid Work Permit During Employment?
Main duties of job

Total time working in Canada	years	months
Do you currently have a valid work permit
If yes, for how many years
Expiry Date

Language Skills

English – Speak
English – Understand
English – Read
English – Write

French – Speak
French – Understand
French – Read
French – Write

Adaptability

Do you have a police record?
If Yes, please explain

Do you have a physical or mental medical condition?
If Yes, please explain

If you have left Canada recently after studying or working in Canada, please give us full details of when you finished your school or work, when you left Canada, and where you live now
Special circumstances or concerns you wish us to know about

Please ensure that all sections above are complete with full details provided. We will reply only to inquiries where full information is provided, and you qualify for immigration to Canada. Thank you for your interest.