IDJADI Immigration Consultancy موسسه مهاجرتی ایجادی

1. UCI

2. Preferred language of service

3. I am applying for one or more of the following

A work permit with the same employer
An initial work permit or a work permit with a new employer
Restoration of my status as a worker
An initial or an extension of a temporary resident permit

PERSONAL DETAILS

1(a). Family name (surname)

1(b). Given name(s)

2(a). Have you ever used any other name?

Yes
No

2(b). Other family name(s)

2(c). Other given name(s)

3. Gender

4. Date of birth

If part of your date of birth is unknown, use * for the unknown component.

5(a). City or town of birth

5(b). Country or territory of birth

6. Country or territory of citizenship

7(a). Current immigration status in Canada

7(b). Other status — specify

7(c). Status — From

7(d). Status — To

8(a). In the past 5 years, have you lived in a country other than your country of citizenship or current residence for more than 6 months?

Yes
No

8(b). Country residence details

Country or territory

Status while there

Other status — specify

From

To

9(a). Current marital status

9(b). Date of marriage or start of current common-law relationship

9(c). Spouse/common-law partner — family name

9(d). Spouse/common-law partner — given name(s)

9(e). Is your spouse/common-law partner a Canadian citizen or permanent resident?

Yes
No

10(a). Have you previously been married or in a common-law relationship?

Yes
No

10(b). Previous spouse/partner — family name

10(c). Previous spouse/partner — given name(s)

10(d). Type of relationship

10(e). From

10(f). To

10(g). Date of birth

LANGUAGE

1(a). First (native) language

1(b). If your native language is not English or French, which language do you use most?

2. Are you able to communicate in English and/or French?

3. Have you taken a test from a designated testing agency to assess your English or French proficiency?

Yes
No

PASSPORT

1. Passport or travel document number

2. Country or territory of issue

3. Issue date

4. Expiry date

5. Are you using a passport issued by the Ministry of Foreign Affairs in Taiwan that shows your personal identification number?

Yes
No

6. Are you using a National Israeli passport?

Yes
No

NATIONAL IDENTITY DOCUMENT

1. Do you have a national identity document?

Yes
No

2. National identity document number

3. Country or territory of issue

4. Issue date

5. Expiry date

U.S. PERMANENT RESIDENT CARD

1. Are you a lawful permanent resident of the United States with a valid alien registration card (green card)?

Yes
No

2. Alien registration card document number

3. Expiry date

CONTACT INFORMATION

Mailing address — use the address where IRCC correspondence should be sent.

1(a). P.O. Box

1(b). Apartment / Unit

1(c). Street number

1(d). Street name

1(e). City / Town

1(f). Country or territory

1(g). Province / State

1(h). Postal / ZIP code

2(a). Is your residential address the same as your mailing address?

Yes
No

2(b). Apartment / Unit

2(c). Street number

2(d). Street name

2(e). City / Town

2(f). Country or territory

2(g). Province / State

2(h). Postal / ZIP code

3(a). Primary telephone location

Canada / United States
Other

3(b). Primary telephone type

3(c). Primary telephone number

3(d). Extension

4(a). Additional telephone location

Canada / United States
Other

4(b). Additional telephone type

4(c). Additional telephone number

4(d). Extension

5(a). Fax location

Canada / United States
Other

5(b). Fax number

6. Email address

COMING INTO CANADA

1(a). Date you first entered Canada

1(b). Place you first entered Canada

2(a). Purpose of your original visit

2(b). If Other, provide details

3(a). Date of your most recent entry to Canada

3(b). Place of your most recent entry to Canada

4. Document number of your most recent Visitor Record, study permit or work permit

DETAILS OF INTENDED WORK IN CANADA

1(a). Type of work permit requested

1(b). If Other, specify the applicable category/reason

Open Work Permit / PGWP: Questions 2–8 below are hidden automatically when either of those categories is selected.

2(a). Employer / school name

2(b). Employer address

3(a). Province of employment

3(b). City / Town of employment

3(c). Employment address

4(a). Job title

4(b). Brief description of duties

5(a). Expected employment — From

5(b). Expected employment — To

6. LMIA number or Offer of Employment number

7(a). CAQ certificate number

7(b). CAQ expiry date

8. Have you been issued a certificate under the Provincial Nominee Program?

Yes
No

EDUCATION

Do you have any post-secondary education, including university, college or apprenticeship training?

Yes
No

From

To

Field of study

School / Facility name

City / Town

Country or territory

Province / State

EMPLOYMENT / WORK / OCCUPATION

Provide employment/activity history for the last 10 years. For co-op and post-graduation work permit applicants, IRCC indicates this section is not required.

1. Current activity — From

1. Current activity — To / Present

1. Activity / Occupation

1. Company / Employer / Facility

1. City / Town

1. Country or territory

1. Province / State

2. Previous Activity / Occupation — past 10 years

From

To

Activity / Occupation

Company / Employer / Facility

City / Town

Country or territory

Province / State

BACKGROUND INFORMATION

All questions in this section must be answered.

1(a). In the past 2 years, have you or a family member had tuberculosis of the lungs or been in close contact with a person with tuberculosis?

Yes
No

1(b). Do you have a physical or mental condition that would require social or health services, other than medication, during your stay in Canada?

Yes
No

1(c). If Yes to 1(a) or 1(b), provide details and the family member's name, if applicable

2(a). Have you ever remained beyond your authorized status, studied without authorization, or worked without authorization in Canada?

Yes
No

2(b). Have you ever been refused a visa or permit, denied entry, or ordered to leave Canada or any other country?

Yes
No

2(c). Have you previously applied to enter or remain in Canada?

Yes
No

2(d). If Yes to 2(a), 2(b), or 2(c), provide details

3(a). Have you ever committed, been arrested for, been charged with, or been convicted of a criminal offence in any country?

Yes
No

3(b). If Yes, provide details

4(a). Have you ever served in the military, militia, civil defence, a security organization, or a police force, including reserve or voluntary service?

Yes
No

4(b). If Yes, provide dates of service and country/countries

5. Have you ever been a member of or associated with a political party, group or organization that engaged in or advocated violence for a political or religious objective, or was associated with criminal activity?

Yes
No

6. Have you ever witnessed or participated in the ill treatment of prisoners or civilians, looting, or desecration of religious buildings?

Yes
No

in recent 10

Review all answers before submitting this client intake.

IMM 5710 – Worker Application Client Intake

8(b). Country residence details

2. Previous Activity / Occupation — past 10 years