JMED (INTERNATIONAL) Corporationtel. (646) 546 5416 Tel. (416) 840 6274 Toll: (877) 437

JMED (INTERNATIONAL) CORPORATION Tel. (646) 546 5416 Tel. (416) 840 6274 Toll: (877) 437 4562 Fax: (866) 925 5001 Email: [email protected] URL: www.jmed.us FB: JMED CANADA AGENCY

IMMIGRATION CONSULTING SERVICES PRE-APPLICATION (CANADA): FILE NO.______/ ______. For the best results, complete all sections of this form. Providing inaccurate or incomplete responses may result in a flawed evaluation. All information provided will be treated with the strictest confidence and shall not be shared with any third-party. Simply type your answers in. Type an “x” to answer yes/no questions. Once you have completed the form simply save a copy for your record and email a copy to us at: [email protected] ANSWER ALL QUESTIONS. If not applicable, type “N/A”. Provide accurate information. Today’s Date (day/month/year): SUMMARY Profession: Diploma obtained: Years worked in profession: Age: Year Graduated: Spouse/ Partner’s Spouse’s diploma: profession: Years spouse worked in Age: Year Graduated: profession: Children (ages): Family in Canada: Yes__ __ No__ __ IDENTIFICATION FAMILY NAME

GIVEN NAMES (First & Middle) COMPLETE NAME (as written in your passport) Date of Birth (day/month/year) Gender (male / female): PLACE OF BIRTH Village/ Town City Province/Region Country

CURRENT COUNTRY OF RESIDENCE (If same as above, type “N/A”) City State/ Province Country Status (citizen; foreign worker, student, legal resident, visitor, etc. …… whether valid or expired)

Comments (if applicable):

PRESENT MARITAL STATUS

Definition of “de facto spouse”: Common-Law partner, unmarried partnership; commonly stated as “boyfriend/girlfriend” or “friend”, who may or will be accompanying you to Canada. The relationship may be of same gender or opposite genders. Single Married De facto spouse Separated Divorced Marriage Widowed (“live-in”) annulled

What is your spouse/ partner’s name: What is your spouse/ partner’s present country of residence:

YOUR TELEPHONE / EMAIL CONTACT

Home Phone No. Cell Phone No. Email Address

Wife’s Telephone No. Skype (if applicable) Twitter / Facebook (if applicable)

Comments (if applicable):

IMMEDIATE FAMILY MEMBERS (Family members—son, daughter (biological / adopted), spouse, etc. who may be accompanying you to Canada)

Family name First name Relationship Age Country of Current Accompanying you to Canada? (Type Residence “Yes” or “No”) Husband or Common- Law (“live-in”) partner

PREVIOUS APPLICATIONS

Have you or any of your immediate family members ever applied: 1. For a temporary stay in Canada? ( ) Yes ( ) No Province? Year:

Result of your application: ( ) Accepted ( ) Denied ( ) Waiting for Decision

2. For permanent immigration to Canada? ( ) Yes ( ) No Province? Year:

Result of your application: ( ) Accepted ( ) Denied ( ) Waiting for Decision

YOUR EDUCATION & TRAINING (Start with your most recent institution attended)

From To Name of Institution & Country Degree/ Diploma obtained AND Year Graduated. (If you (month/year) (month/year) did not complete the degree, type “INC”).

Total the Number of Years of education you have completed (starting with elementary school): __ __

YOUR EMPLOYMENT HISTORY Employment during the past 10 years, including military service (start with your most recent job) Name of Company No. Hours From To including country where it is located and industry type Job Title Worked (month/year) (month/year) (JMED will not contact your employers) per Week?

Comments:

SPOUSE / PARTNER’S EDUCATION & TRAINING (if applicable and available) Degree/ Diploma obtained (If you did not complete From To Name of Institution & Country the degree, type “INC”. You may include vocational diplomas / (month/year) (month/year) certificates)

SPOUSE / PARTNER’S EMPLOYMENT HISTORY Employment during the past 10 years, including military service (start with your most recent job) Name of Company No. Hours From To including country where it is located and industry type Job Title Worked (month/year) (month/year) (JMED will not contact employers) per Week?

CANADIAN & U.S TRAVEL (Optional) (Having traveled to, and overstayed in, the U.S / Canada does mean you cannot apply. Possessing a valid or expired visa does not mean you cannot be eligible to apply. We require this information in order properly guide you.) Country Year of Last entry Type of visa (Cdn- Comments (if any) (U.S or Canada only) (year only) work, study, visit. U.S.A.: B1/B2, F-1, H1-B, etc)

ENGLISH LANGUAGE SKILLS Self Ratings English None Beginners Intermediate Advanced  Understand spoken [ ] [ ] [ ] [ ]  Ability to speak [ ] [ ] [ ] [ ]

Have you ever enrolled in a English training class before: ( ) Yes ( ) No Have you ever taken a standardized English examination before: ( ) Yes ( ) No Name ______

FAMILY OR FRIENDS IN CANADA (who are 18 years or older and are legal permanent residents or citizens of Canadian) Relationship First and Family name City Province

DECLARATION MUST be completed: I certify that the information that I have provided is accurate and I am willing to provide additional information (if required by JMED CORPORATION) for the completion of this assessment. I consent to JMED corresponding with me at the e-mail address provided above. I also understand that knowingly and/or willfully providing false information herein can negatively impact my application. I am also authorizing JMED CORPORATION to represent or, act on, my behalf in matters respect to this application. Type your full name below as a testimony that the information that you provided is accurate and complete to the best of your knowledge.