Url First Name * (as in passport) Last Name * Gender * Select Male Female Date of Birth * Country of Birth * Town or City * Marital Status Married * Select Yes No Applying WITH your Spouse Select Yes No Is your Spouse accompanying you * Select Yes No Is your Spouse a Canadian PR or citizen * Select Yes No Personal Details (of your Spouse) Spouse First Name Spouse Last Name Spouse Gender Select Male Female Spouse Date of Birth Spouse Country of Birth Spouse Birth City or Town Immigration History and Citizens Applied to CIC before * Select Yes No If YES, ever applied for Express Entry before Select Yes No Your CIC UCI number Country (countries) of Citizenship Country of Current Residence Status in Country of Current Residence Family How many family members in your application? * Funds available to support family (CDN $) * Whether accompanying you to Canada or not Relatives in Canada (attach additional page for more details) Relative in Canada 18yrs+ Select Yes No (citizen or PR currently living in Canada) Realtationship to you Province/Territory where relative resides Contact Details Language of Correspondence Email Address Education Study Finished High School or any higher education Select Yes No Field of Study Higher Study From year Higher Study To year This is my current study Select Academic years (number of years for above mentioned study) Transcript available to support answer above Select Yes No Full-Time or Part-Time Study Select F/T P/T Status of Completion Country of Study City/Town of Study Name of School/Institution Awarded a Canadian degree, diploma or certificate If YES, please submit copy plus transcript with Select Yes No Educational Credential Assessment completed Yes No Name of ECA provider (eg. WES) Date of Language Test Date of Test Results Language Test Certificate Number * Breakdown of score: Speaking Reading Listening Writing Application Details Which Province or Territory to consider living in? I authorize CIC and Province/Territory to collect my information and share with potential employers Select Yes No Do you have an approved Provincial Nomination? If YES, please submit copy with this questionnaire Select Yes No PNP is for which Province/Territory I have studied full-time in Canada for 2 years or more Select Yes No I have at least 2 year of full-time work experience in Canada (NOC 0, A or B) Select Yes No I have a relative in Canada who is 18 years or older, a citizen or PR of Canada, and is my parent, child, Select (grandparent, grandchild, sibling, aunt, uncle, niece or nephew (yes/no)) Primary occupation (by NOC code) Date first became qualified for this occupation (YYYY/MM) Worked in Canada in past 3 years Select Yes No Canadian Certificate of Qualification (CoQ) Do you possess a Canadian CoQ Select Yes No CoQ is for which Province/Territory 4-digit NOC code of CoQ CoQ obtained on (YYYY/MM/DD) Date of issuance (YYYY/MM/DD) Intended Work in Canada Do you have a Job offer in Canada Select Yes No Is this Job full-time non-seasonal and permanent Select Yes No 4-digit NOC code of the Job Job Title How many employers made this Job offer (number) Is employer an Embassy, Consulate or High Commission Select Yes No Is employer on list of ineligible employers with the Government of Canada Select Yes No Employer or Company name Contact address of employer or company Intended location of employment Unit No., Street address and Province LMIA or Job Offer Was a Positive LMIA issued for the job offer Select Yes No If YES, please submit copy with this questionnaire LMIA number Are you currently working in Canada LMIA issue date LMIA expiry date Work History Do you have work history Select Yes No EMP 1: Starting From Date Is this current job Select Yes No To Date Hours of work per week 4-digit NOC code Job Title Employer/company name Self-employed Select Yes No Where (Country/City) EMP 2: Starting From Date Is this current job Select Yes No To Date Hours of work per week 4-digit NOC code Job Title Employer/company name Use of a Representative Form I have completed, signed and attached the Use of a Representative Form (IMM 5476) Select Yes No By signing below, I confirm and attest to the ACCURACY of all information provided in this document, to which I attach my completed and signed IMM5476 Select Yes No PRINT NAME IN FULL City/Country where Completed and Signed Express Entry Questionnaire Submission I hereby submit ALL competed pages and my signed IMM 5476, plus additional pages as required, on today’s date as noted above Select Yes No
