Murchie Immigration Consultancy, LLC
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Express Entry Form

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Express Entry Questionnaire

Please complete the following form:

Prospective Client Name: *
Prospective Client Name:
Home Phone:
Home Phone:
Work Phone:
Work Phone:
Cell Phone:
Cell Phone:
Date of Birth:
Date of Birth:
Type of Identification: Number: Date of Issue (DD/MM/YYYY): Expiry Date (DD/MM/YYYY):
Background Information
If yes, select any of the categories below:
Secondary Education
Post-Secondary Education (Bachelor's, Masters, or Ph.D):
Name of College or University: Number of years of study: City/Country: Study Period: from (MM/YYYY) to (MM/YYYY) Did you graduate? If yes, what year did you graduate? Type of diploma or degree: Name of program: Full-time or part time studies:
Work Experience
Provide the following information for your previous work experience: Name of Employer: From (MM/YYYY) to (MM/YYYY): City/Country: Hours per week: Job Title: If a Canadian employer, please provide full address: MAIN DUTIES (describe the daily tasks that you regularly performed):
Industrial, electrical and construction trades. Maintenance and equipment operation trades. Supervisors and technical jobs in natural resources, agriculture and related production. Processing, manufacturing and utilities supervisors and central control operators. Chefs and cooks. Butchers and bakers.
Language (English)
Date taken: Type of Test (IELTS/CELPIP): Reference No.: Scores per ability Speaking: Listening: Reading: Writing:
Language (French)
Date taken: Type of Test (IELTS/CELPIP): Reference No.: Scores per ability Speaking: Listening: Reading: Writing:
Information About Spouse
Spouse's Name:
Spouse's Name:
Date of Birth:
Date of Birth:
Home Telephone
Home Telephone
Type of Identification: Number: Date of Issue (DD/MM/YYYY): Expiry Date (DD/MM/YYYY):
Province: Nomination date:
How many years of elementary and secondary education did your spouse complete? Elementary: Secondary:
Type of certificate: School name: Year of graduation:
Name of College or University: Number of years of study: City/Country: Study Period: from (MM/YYYY) to (MM/YYYY) Did you graduate? If yes, what year did you graduate? Type of diploma or degree: Name of program: Full-time or part time studies:
Provide the following information for your previous work experience: Name of Employer: From (MM/YYYY) to (MM/YYYY): City/Country: Hours per week: Job Title: If a Canadian employer, please provide full address: MAIN DUTIES (describe the daily tasks that you regularly performed):
Spouses's Language Ability (English)
Date taken: Type of test (IELTS/CELPIP): Reference No.: Scores per ability: Speaking: Reading: Listening: Writing:
Spouses's Language Ability (French)
Date taken: Type of test (IELTS/CELPIP): Reference No.: Scores per ability: Speaking: Reading: Listening: Writing:
Proof of Funds
Location
In which of the following provinces and territories would you be prepared to live?
Check all that apply
Information About Your Children
Name: Gender: Date of Birth: ID Number Include & National ID (if applicable): Date of issue (DD/MM/YYYY): Expiry date (DD/MM/YYYY): Marital status: Coming to Canada with you? (Y/N)
Declaration
Signature
Signature
Date
Date