Nom de famille*

Prénom(s)*

Adresse*

Ville*

Province/État*

Code postal*

Pays de résidence actuel* Afghanistan ÅLAND, ÎLES Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ascension Island Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands CORÉE, RÉPUBLIQUE POPULAIRE DÉMOCRATIQUE DE Costa Rica CÔTE D'IVOIRE Croatia Cuba Cyprus Czech Republic Denmark Diego Garcia Djibouti Dominica Dominican Republic East Timor Easter Island Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Antilles French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guantanamo Bay Guatemala GUERNESEY Guinea Guinea-Bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland ÎLE DE MAN INCONNU India Indonesia Iran, Islamic Republic of Iraq Ireland Israel Italy Jamaica Japan JERSEY Jordan Kazakhstan Kenya Kiribati Korea, Republic of Kosovo Kuwait Kyrgyzstan LAO, RÉPUBLIQUE DÉMOCRATIQUE POPULAIRE Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Lord Howard Island Luxembourg Macao Macedonia, the Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia MONTÉNÉGRO Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines SAINT-BARTHÉLEMY Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia-Montenegro SERBIE SERBIE Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.s. Wallis and Futuna Western Sahara Yemen Yougouslavie Zambia Zimbabwe

Pays avant immigration (si au Canada)* Afghanistan ÅLAND, ÎLES Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ascension Island Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands CORÉE, RÉPUBLIQUE POPULAIRE DÉMOCRATIQUE DE Costa Rica CÔTE D'IVOIRE Croatia Cuba Cyprus Czech Republic Denmark Diego Garcia Djibouti Dominica Dominican Republic East Timor Easter Island Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Antilles French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guantanamo Bay Guatemala GUERNESEY Guinea Guinea-Bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland ÎLE DE MAN INCONNU India Indonesia Iran, Islamic Republic of Iraq Ireland Israel Italy Jamaica Japan JERSEY Jordan Kazakhstan Kenya Kiribati Korea, Republic of Kosovo Kuwait Kyrgyzstan LAO, RÉPUBLIQUE DÉMOCRATIQUE POPULAIRE Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Lord Howard Island Luxembourg Macao Macedonia, the Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia MONTÉNÉGRO Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines SAINT-BARTHÉLEMY Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia-Montenegro SERBIE SERBIE Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.s. Wallis and Futuna Western Sahara Yemen Yougouslavie Zambia Zimbabwe

Date de naissance*

Pays de naissance* Afghanistan ÅLAND, ÎLES Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ascension Island Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands CORÉE, RÉPUBLIQUE POPULAIRE DÉMOCRATIQUE DE Costa Rica CÔTE D'IVOIRE Croatia Cuba Cyprus Czech Republic Denmark Diego Garcia Djibouti Dominica Dominican Republic East Timor Easter Island Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Antilles French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guantanamo Bay Guatemala GUERNESEY Guinea Guinea-Bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland ÎLE DE MAN INCONNU India Indonesia Iran, Islamic Republic of Iraq Ireland Israel Italy Jamaica Japan JERSEY Jordan Kazakhstan Kenya Kiribati Korea, Republic of Kosovo Kuwait Kyrgyzstan LAO, RÉPUBLIQUE DÉMOCRATIQUE POPULAIRE Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Lord Howard Island Luxembourg Macao Macedonia, the Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia MONTÉNÉGRO Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines SAINT-BARTHÉLEMY Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia-Montenegro SERBIE SERBIE Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.s. Wallis and Futuna Western Sahara Yemen Yougouslavie Zambia Zimbabwe

Genre*

Langue principale* Albaneese Amharic Arabic Bengali Bulgarian Chinese Corean Danish Anglais Estonian Farsi Filipino Finnish Flamand (Dutch) Français German Greek Hébreu Hongarian Indonesian Italian Japanese Norway Polish Portugese Romanian Russe Serbian Slovenian Spanish Sweedish Thaï Turk Tzech Ukrainien Vietnamese Yiddish Zulu

Niveau de Français* Fluent Functional Basic None

Niveau d'Anglais* Fluent Functional Basic None

Statut d'immigration actuel* Permanent resident Permis de travail Permis d'études Visitor permit Canadian citizen Work - holiday program Visitor

Canadien de retour au Canada*

Date d'entrée au Canada*

Téléphone principal*

Téléphone secondaire

Courriel principal*

Courriel secondaire