H&C Intake Form

Full Name
Email Address
Have you used any other name before?
Over the past 5 years, have you spent more than 6 months continuously in any country other than your country of residence or citizenship?
Date FromDate ToStatus in the Country
Date FromDate ToStatus in the Country
Date FromDate ToStatus in the Country
Date FromDate ToStatus in the Country
What is your Marital Status
Have you been married or in Common-Law relationship before

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Have you ever been refused a visa to Canada or any other Country
Have you previously applied to enter or remain in Canada?
Have you or your family member had tuberculosis or was in contact with a person with tuberculosis in the past 2 years
Have you ever committed, been arrested, been charged with or convicted of any criminal offence in any country?
Do you have any physical or mental disorder that require social/health services, other than medications for your stay in Canada ?
.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)
Have you ever remained in Canada after your status expired, attended school or worked without authorization
Have you ever been refused visa/permit, denied entrance or ordered to leave Canada/other country?
.Have you ever witnessed or participated in the ill treatment of prisoners or civilians, looting or desecration of religious buildings
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 achieving a political or religious objective, or which has been associated with criminal activity at any time?

Work History

Begin with the most recent employer; describe work history for the past 10 years . Do not leave any gaps in time, if you were unemployed, put “Unemployed”.
Address
Address (copy)