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Tseliou Immigration Consulting Services Inc.

www.icsgr.com
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PRE-ASSESSMENT FORM: To be completed by the applicant. Failure to be truthful and accurate can result and
jeopardize your immigrant chances.

A. CONTACT INFORMATION
NAME:PARID LAST NAME:OHRI MIDDLE NAME: FIRST NAME

ADDRESS: Rr.”Dhimiter Kamarda” Pall.10


Sh 1. Ap16 Tirana/Albania

CELL PHONE:+355695892888

HOME PHONE:

EMAIL: parid.ohri@gmail.com

B. PERSONAL INFORMATION
C. F
MALE X FEMALE A
M
BIRTH DATE: MONTH DAY YEAR IL
Y

PLACE OF BIRTH CITY COUNTRY

COUNTRY OF CITIZENSHIP

COUNTRY OF RESIDENCE

STATUS IN COUNTRY OF RESIDENCE

CURRENT MARITAL STATUS MARRIED COMMONLAW NEVER MARRIED DIVORCED

DATE OF MARRIAGE

DATE OF DIVORCE

INFORMATION

NUMBER OF CHILDREN

NAME FIRST MIDDLE LAST


DATE OF BIRTH

SEX MALE FEMALE

MARITIAL STATUS SINGLE MARRIED DIVORCED

NAME FIRST MIDDLE LAST

DATE OF BIRTH

SEX MALE FEMALE

MARITIAL STATUS SINGLE MARRIED DIVORCED

NAME FIRST MIDDLE LAST

DATE OF BIRTH

SEX MALE FEMALE

MARITIAL STATUS SINGLE MARRIED DIVORCED

NAME FIRST MIDDLE LAST

DATE OF BIRTH

SEX MALE FEMALE

MARITIAL STATUS SINGLE MARRIED DIVORCED

D. LANGUAGE

E. EDUCATION

ELEMENTARY COMPLETED NOT COMPLETED CERTIFICATE/DIP/DEGREE

HIGH SCHOOL

COLLEGE

UNIVERSITY

MASTERS DEGREE

PHD
F. WORK EXPERIENCE (last 10 years)

NAME OF COMPANY POSIITON NUMBER OF YEARS


G. BUSINESS EXPERIENCE

TYPE OF COMPANY POSITION

H. CRIMINIAL CHARGES

CHARGE DATE OF CONVICTION DATE SENTENCE COMPLETED

I. IMMIGRATION HISTORY

NAME OF COUNTRY STATUS IN COUNTRY DEPORTED

J. ANY OTHER INFORMATION YOU WOULD LIKE TO LET ME KNOW.

DECLARATION:

I declare that the information I have given to Immigration Consulting Services Inc. are accurate, true and complete. I understand that any false or concealment
or a material fact may result in severe consequences as per Canadian immigration laws including detention and or deportation.

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SIGNATURE PRINT NAME DATE

INTERPRETER:

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SIGNATURE PRINT NAME Date