1. Family name

2. Given name

3. Your birth date?

4. Country of Citizenship :

:.....................................................................

5. Marital Status :

:.....................................................................

6. Current Mailing Address - House/ Street Number :

:.....................................................................

7. Current Mailing Address (Continued) :

:.....................................................................

8. City / Town :

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9. Province / State :

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10. Country of residence :

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11. Postal / ZIP Code :

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12. Telephone Country Code :

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13. Telephone City Code :

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14. Home Telephone number :

.............................Extension (If any) ...........

15. Alternate Telephone number :

.............................Extension (If any) ...........

16. Email address

:.....................................................................

If you are using a free mail account, we recommend yahoo, gmail or hotmail.

17. Language ability

:.....................................................................

18. Any trips to Canada in the last 5 years

:.....................................................................

Which province?

:.....................................................................

19. Reason of visit

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20. Owned business in the past 5 years. If yes, please answer questions 20a & 20b and then continue to question 22, If not, please skip to question 21

a. Percentage of company owed

:.....................................................................

b. Number of people managed

:.....................................................................

21. Managerial experience for the last 5 years

:.....................................................................

a. Number of people managed

:.....................................................................

b. Did company have a Loss or Profits in the last 2 years

:.....................................................................

22. Details of Business Activities: Include, type of business, your position/role within the business and job duties

:.....................................................................

:.....................................................................

:.....................................................................

:.....................................................................

23. Net Worth: $(CAD) Business Assessets including your spouse (if applicable)

:.....................................................................

a. Method of accumulation (inheritance, investment, business ect.)

:.....................................................................

:.....................................................................

:.....................................................................

:.....................................................................

:.....................................................................

24. Does the following apply to you or any family member (wife or children)

a. Medical problem

:.....................................................................

b. Convicted or charged for criminal activity

:.....................................................................

c. Refused entry into Canada or any other country

:.....................................................................

If yes, please provide details here:

:.....................................................................

25. How did you find our website?

:.....................................................................

a. Other - Please Specify

:.....................................................................