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investors Program ASSESSMENT REQUEST

Please fill in the following spaces and click on submit button. Our staff will process your request and contact you shortly.

Personal Specifications
- Family Name at Birth:
- Name:
- Other Name that you have used or by which you are known by:
- Sex:
- Date of Birth (YYYY-MM-DD):
- Birth Place (Province - Region):
- Birth Place (Country):
- Citizenship:
- Present Marital Status:

Address Specifications
- Residence Address (number, street, app.):
- Postal Code:
- City/Province/Country:
- Phone no.  Home-Work (Please include the country code):
- Fax no. Home-Work (Please include the country code):
- Email Address  Home-Work:

Language Ability
- French:
      Understand Spoken:
      Ability to Speak:
- English:
      Understand Spoken:
      Ability to Speak:
- Education
- Education Highest Level:
- In what country did you obtain this diploma:
- What is the field of training related to this diploma:
- How many years ago did you obtain this diploma:

Work experience
- Do you have professional management experience?
If yes please provide the following details:
- Name of the Organization:
- Worked From (Mm/YYYY/DD):    to (Mm/YYYY/DD):
- Number of employees under your authority:
- Location (City-Province-Country):
- Type of Organization:
- Title/Position:
- Details on your role and duties within the Organization:
Please indicate the total value of your personal Net worth in Canadian dollars:
- Method of accumulation of personal Net worth ( business, investment, inheritance):

Relative in Canada
- Do you already have family in Canada?
- Have you ever traveled to Canada in the past 10 years?
- Number of trips to Canada?
- Province:
- Reason of visit:

Spouse Specifications - if applicable
- Present Marital Status:
- Family Name at Birth and Present Family Name:
- First Name:
- Sex:
- Date of Birth (YYYY/MM/DD):
- Place of Birth- Province-Region:
- Place of Birth- Country:
- Citizenship:
- Education- Highest Level:

Children Specifications
- Number of children
- Age from to
Does the following apply to you, your spouse or any of your children?
- Medical problem:
- if yes, please explain:
- Convicted of or charged with a crime or offence:
- if yes, please explain:
- Refused entry in Canada or any other Country:
- if yes, please explain:

- How did you learn about us?


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