Assessment Form Let’s get you on your way to that fulfilled dream. Fill Out Our Assessment Form Assessment Form PART 1 - Personal Information Please review the following questions and answer them to the best of your ability. Name * First Name Last Name Email * Phone * (###) ### #### Birth Date * MM DD YYYY Address * Please list your residential address. Address 1 Address 2 City State/Province Zip/Postal Code Country Do you have any dependent children? * Please let us know if you have any children. Yes No If you answered YES to the previous question, please provide the ages of your children. What is your country of nationality? * Please state the country in which you were born. What is your primary language? * Please tell us your first language/mother tongue. List the names of countries that you have visited outside of your country of nationality within the past 10 years. Please include Country or Territory, travel dates and purpose of travel. * PART 2 - Education/Employment Please review the following questions and answer them to the best of your ability. Which program do you intend to pursue in Canada? This query applies to Study Permit Applicants only. Please list the highest level of education completed. * None High School Education/GED Undergraduate/Associate Degree Bachelor's Degree Master's Degree Doctorate Other Please note your anticipated program start date. This query is for Study Permit Applicants only. MM DD YYYY Please list any programs you have completed including your CGPA (Cumulative Grade Point Average) Who will sponsor your travel to Canada? Self Parent/Guardian Spouse Other What is your current occupation? * How many years of work experience do you have? * PART 3 - English Proficiency Please review the following questions and answer them to the best of your ability. Do you have a valid English proficiency result? * This refers to your IELTS results. Yes No If you answered 'YES' to the previous question, please enter the date your exam was written. MM DD YYYY Please list your Speaking scores. 0-4 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 Please list your Listening scores. 0-4 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 Please list your Reading scores. 0-4 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 Please list your Writing scores. 0-4 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 PART 4 - Background Information Please review the following questions and answer them to the best of your ability. Within the past two years, have you or a family member ever had tuberculosis of the lungs or been in close contact with a person with tuberculosis? * Yes No Do you have any physical or mental disorder(s) that would required social and/or health services, other than medication, during a stay in Canada? * Yes No If you answered YES to the two questions under this section, please list the name and details of the family member (if applicable). PART 5 - Status Please review the following questions and answer them to the best of your ability. Have you ever remained beyond the validity of your status, attended school without authorization or worked without authorization in Canada? * Yes No Have you ever been refused a visa or permit, denied entry or ordered to leave Canada or any other country or territory? * Yes No Have you previously applied to enter or remain in Canada? * Yes No If you answered 'Yes' to Question 5.1, 5.2 and 5.3, please provide details. PART 6 - Additional Background Information Please review the following questions and answer them to the best of your ability. Have you ever committed, been arrested for, or been charged with or convicted or any criminal offence in any country or territory? * Yes No If you answered YES to the previous question, please provide details. Did you serve in any military, militia or civil defense unit or serve in a security organization or police force (including non-obligatory national service, reserve or volunteer units)? * Yes No If you answered YES to the previous question, please provide the dates of service, and countries or territories where you served. Are you, or have you ever been a member or associated with any political party, or other group or organization which has engaged in or advocated violence as a means to achieve a political or religious objective, or which has been associated with criminal activity at any time? * Yes No Have you ever witnessed or participated in the ill treatment of prisoners or civilians, looting or desecration or religious buildings? * Yes No Have you ever held any government positions (such as civil servant, judge, police officer, mayor, member of Parliament, hospital administrator? * Yes No If you answered YES to the previous question, please provide details. How did you hear about us? Facebook Instagram Word of Mouth Thank you for choosing HisCharis Immigration & Citizenship Services! A member of our team will review your responses and reach out to you as soon as possible.
