Express Entry Assessment Form

*Given Name (first name) as in passport

Gender

Male

Female

*Family Name (last name) as in passport

*Email

*Phone Number

Date of birthYYYY/MM/DD

Upload copy of birth certificateMultiple Upload (ctrl + Select Multiple Files)

Country of Birth

City/Town of Birth

Given Name (first name) as in passport (Spouse)

Family Name (last name) as in passport (Spouse)

Gender (Spouse)

Male

Female

Date of birth (Spouse)YYYY/MM/DD

Country of Birth (Spouse)

City/Town of Birth (Spouse)

Passport or Travel Document

YES

NO

Passport Number

Issue DateYYYY/MM/DD

Expiry DateYYYY/MM/DD

Applied to CIC before

YES

NO

If YES, ever applied for Express Entry before

YES

NO

Your CIC UCI number

Country (countries) of Citizenship

Country of Current Residence

Status in Country of Current Residence

How many family members in your application? Whether accompanying you to Canada or not

Funds available to support family (CDN $)

Language of Correspondence

English

French

*Email (Contact Detail)

Level of Education

Name of School/Institution

Please upload copy of ECA report

Language Test name ( ie: IELTS general, CELPIP general, TEF): Please upload copyMultiple Upload (ctrl + Select Multiple Files)

Name of ECA provider (eg. WES)

Date of Report YYYY/MM/DD

Certificate # as on original Report

Education Level Equivalent as on Report

Test taken (eg. IELTS, CELPIP)

Uplod Your CopyMultiple Upload (ctrl + Select Multiple Files)

Date of Language TestYYYY/MM/DD

Date of Test ResultsYYYY/MM/DD

Speaking

Reading

Listening

Writing

Test taken (eg. IELTS, CELPIP) (Spouse)

Uplod Your Copy (Spouse)Multiple Upload (ctrl + Select Multiple Files)

Date of Language Test (Spouse)YYYY/MM/DD

Date of Test Results (Spouse)YYYY/MM/DD

Speaking (Spouse)

Reading (Spouse)

Listening (Spouse)

Writing (Spouse)

I have studied full-time in Canada for 2 years or more

YES

NO

I have at least 2 year of full-time work experience in Canada (NOC 0, A or B)

YES

NO

Primary occupation (by NOC code)

Date first became qualified for this occupationYYYY/MM/DD

CoQ is for which Province/Territory

Date of issuanceYYYY/MM/DD

4-digit NOC code of CoQ

CoQ obtained onYYYY/MM/DD

Do you have a Job offer in Canada

YES

NO

Is this Job full-time non-seasonal and permanent

YES

NO

4-digit NOC code of the Job

Job Title

Is employer on list of ineligible employers with the Government of Canada

YES

NO

Is employer an Embassy, Consulate or High Commission

YES

NO

Employer or Company name

Intended location of employment

Contact address of employer or company

Street address and Province

Was a Positive LMIA issued for the job offerIf YES, please submit copy with this questionnaire

YES

NO

Language Test version (eg. General)

LMIA issue dateYYYY/MM/DD

Upload Your Copy

LMIA number

LMIA expiry dateYYYY/MM/DD

EMP 1: Starting From Date (year/month)

EMP 1: To Date (year/month)

EMP 1: 4-digit NOC code

EMP 1: Employer/company name

EMP 1: Where (Country/City)

Is this current job

YES

NO

EMP 1: Do you have work history

YES

NO

EMP 1: Hours of work per week

EMP 1: Job Title

EMP 1: Self-employed

YES

NO

EMP 2: Starting From Date (year/month)

EMP 2: To Date (year/month)

EMP 2: 4-digit NOC code

EMP 2: Employer/company name

EMP 2: Where (Country/City)

EMP 2: Is this current job

YES

NO

EMP 2: Hours of work per week

EMP 2: Job Title

EMP 2: Self-employed

YES

NO

EMP 3: Starting From Date (year/month)

EMP 3: To Date (year/month)

EMP 3: 4-digit NOC code

EMP 3: Employer/company name

EMP 3: Where (Country/City)

EMP 3: Is this current job

YES

NO

EMP 3: Hours of work per week

EMP 3: Job Title

EMP 3: Self-employed

YES

NO

Marital Status

Personal Details (for your Spouse)

ID Documents - Summary

Immigration History and Citizenships (attach additional page for more details)

Family

Relatives in Canada (attach additional page for more details)

Contact Details

Education Study (attach additional page for more details)

If YES, please submit copy plus transcript with this questionnaire

Languages (attach additional page for more details – if also tested in French)

Breakdown of score: (Speaking/Reading/Listening/Writing)

Languages (for your Spouse)

attach additional page for more details – if also tested in French

Breakdown of score: (Speaking/Reading/Listening/Writing)

Application Details

You must agree to register for Express Entry

If YES, please submit copy with this questionnaire

Occupation

Canadian Certificate of Qualification (CoQ)

Intended Work in Canada

LMIA or Job Offer

Work History

(List all work experience only in NOC 0, A or B – over past 10 years. Apprenticeship not included. Attach additional page, if required, for more details.)

Use of a Representative Form

One World Immigration Canada

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