Personal Information

*First Name 
Middle Name 
*Last Name 
Gender 
*Date of Birth 
 ,
*Marital Status 

Contact Information

*Address 
City 
State/Province 
*Country 
Postal/Zip Code 
*Home Phone 
Country Cd.    Area Cd.        Phone No.
 -  - 
Cell Phone 
Country Cd.    Area Cd.        Phone No.
 -  - 
Fax 
 -  - 
*Email Address 

Note: Your results will be sent to this address

Immigration Specific Information

*What is your citizenship? 
*What do you want to do? 
Where do you intend to live in Canada? 
*Do you have friends and/or family in Canada? 
*How many people will accompany you? 

Have you or any one else included in this application ever been convicted of a criminal offence?
Have you or anyone else included in this application ever been denied entry into Canada/United States or any other country for any reason whatsoever?
Have you or anyone else included in this application ever been involved in the commission of a war crime or a crime against humanity?
Have you or anyone else included in this application ever had any serous disease or physical or mental disorder?
Are you facing any criminal charges, or awaiting the outcome of an immigration inquiry?

Educational Background

How many years did you spend in...
*Elementary school? 
*Secondary school? 
*Post-secondary education or training? 

*What is the highest educational/training qualification you achieved? (eg: High School Diploma, Bachelors, Masters, Ph.D, etc.) 

Proficiency in English

  None Basic Moderate High
Read
Write
Speak
Listen
Proficiency in French

  None Basic Moderate High
Read
Write
Speak
Listen

Work Experience/History

*What has been your work experience? (please attach resume, if possible) 
*How many years have you worked full-time? 

PLEASE COMPLETE BELOW

*When would you like to start your process?
*How did you hear about us? 




GLBT Immigration is licensed & insured by the Canadian Society of Immigration Consultants (CSIC)
and is a member of the Canadian Association of Professional Immigration Consultants (CAPIC)

Members in good standing of CSIC working with GLBT Immigration:
Hugh W. Coulthart, MA, LLB (M074334) • Nir Rozenberg, CCIC (M074326)
Immigration strategies for the gay, lesbian, bi-sexual, and transgendered community.
Partial list of services include: Spousal sponsorship, work permits, study-student permits,
skilled worker applications, refugee claims, H&C applications, and more.

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