IIEC

Assessment Form

1. (i).Surname / Last Name

(ii).First Name

(iii).Middle Name

2. Email address:

3. Sex

Male Female

4. Resident of

5.Date of Birth(Age) (eg:2009/06/15)

6. Place of Birth: City/Town & Country

7. Permanent Home Address

8. Current Mailing Address

9. Telephone Number

10. Country you wish to study

11. Present Marital Status

Number of Kids

12. Education:

Total years of primary and secondary schooling

Total years of post Secondary Education

Graduation(Details of Diploma & Duration)

Post Graduation (Details of Diploma & Duration)

College (Details of Diploma and Duration)

Technical certificate of Diploma (Details of Diploma & Duration)

13. Ability in Language - ENGLISH:

Speak	High	Moderate	Basic	None
Listen	High	Moderate	Basic	None
Read	High	Moderate	Basic	None
Write	High	Moderate	Basic	None

14. Ability in Language - French:

Speak	High	Moderate	Basic	None
Listen	High	Moderate	Basic	None
Read	High	Moderate	Basic	None
Write	High	Moderate	Basic	None

15. Years of Formal Apprenticeship / Internship / Training Work History

16. Total number of years of experience

17. Work History for Past 10 Years: (Provide position & short description of duties)

1.

2.

3.

18: *If you or any family member is having serious disease like HIV/Cancer/Hepatitis

SPOUSE DETAILS

1.(i).Surname / Last Name:

1.(ii).First Name

1.(iii).Middle Names

2. Date of birth(eg:2009/06/15)

3. Education:

Total years of primary and secondary schooling

Total years of post Secondary Education

i) Graduation (Details of Diploma & Duration)

ii) Post Graduation (Details of Diploma & Duration)

iii) College (Details of Diploma & Duration)

Technical certificate of Diploma (Details of Diploma & Duration)

4. Ability in Language

ENGLISH

5. Ability in Language

French

6. Work History(Provide position & short description of duties)

Work History for Past 10 Years:

1.

2.

3.

4.

5.

Fund Available for Settlement in Canada:(Any liquid fund available in Bank or Fixed deposits, can be transfer while immigrating to Canada. Should be in the name of the applicant or in the name of Spouse)

Signature of the Applicant

Place

Date