Immigration agents, complete section 1 only.

section 1.

Name:

Company name (if any):

Address:

City:

Province/State:

Country:

Postal code/Zip/Etc.:

Phone:

Fax:

E-mail:

You would prefer to be contacted by:
Phone
E-mail

Immigration agents, check this option and click on the SEND button below.
I’m acting as agent for advisor to potential clients.

section 2.

1. Gender
Male Female

2. Marital status
Single Married Separated Divorced

3. Age

4. Do you have professional management experience?
Yes No

If yes, provide the following information on the last business you’ve been involved in:

Name of organization:

From (month/year) to (month/year)

Location:

Type of organization:

Title/Position:

Duties:

5. Please indicate the total value of your assets (including fixed assets and liquid assets) and current liabilities, in either Canadian or US dollars.
Specify: Canadian dollars US dollars

Assets:
Liabilities:

6. Do you already have family in Canada?
Yes No

7. Have you ever travelled to Canada?
Yes No

8. Please specify your language abilities with regard to Canada’s official languages.

English	Fluently	Well	With difficulty	Not at all
Speak
Read
Write

French	Fluently	Well	With difficulty	Not at all
Speak
Read
Write

9. Are you also interested in 100%-secure tax-free investments?
Yes No

10. Any questions or comments?