Your name: First Name Last Name

Your Email Address:

Address: (in max 150 characters)

Telephone:

Fax:

Citizenship Country:

Country of Residence: The country where you currently live.

Your Date of Birth: Date (DD) Month (MM) Year (YYYY)

Maritial Status: Married
Unmarried

Immigration Category: Refugee Status Seeker
This form will provide us essential information to assist you with your refugee application.

Dependent Children: include all unmarried children, who are less than 22 years old or who have been continuously studying since the age of 22 years.

Language

Have you previously sought refugee status in Canada or applied for an immigrant or visitor visa Yes NO

If yes, please explain

Have you been refused refuge status in, or immigrant or visitor visa to Canada or any other country? Yes NO

If yes, please explain

Are you in your country of citizenship or habitual residence? Yes No

If yes, please explain

Have you ever applied for convention refugee status with the United Nation high commissioner for refugees.(UNHCR)? Yes No

If yes, please explain

Have you been refused refugee status by the country in which you are currently living in or in any other country? Yes No

If yes, please explain

Can you build a life in the country in which you are now located? Yes No

please explain

Are you in danger in the country where you are now living? Yes No

please explain

Will you be able to return to the community you are fleeing? Yes No

please explain

Have ever been detained or put in Jail Yes No

If yes, please explain

Have you ever been associated with any organizations, such as political, social or any other organizations Yes No

If yes, please explain

Why do you consider your-self as a refugee?

please explain