Somira Canada Group

Assessment Form
The following information will be used for the purpose of providing written recommendations
regarding visiting or immigrating to Canada. Your personal information will only be used for
analyzing your family situation and helping you to choose an immigration program suitable for
your needs. Please pay special attention to questions concerning your future educational and
career goals in Canada. This information will help us to better assist you in creating your
personal immigration plan. If needed, we may request additional information about you and
your family members.
We keep strict standards of confidentiality.

Family Name(s):
Maxim

Given Name(s):
Ion

Age:
22

Place of Birth (City/Town, Country) :

Frsineti/ Ungheni, Republic of Moldova

Citizenship(s):

Moldovan and romanian citizenships

Current place of residence (City/Town, Country) :

Suceava, Romania

Telephone number:
+37323645470

E-mail address:

maxim.ion93@gmail.com

Skype:

maxym-1234

Your current marital status:

single

Provide the following details for your current spouse/common-law

partner:
Family name:

Given name:

Age:

Place of Birth (City/Town, Country) :

Citizenship(s):

Provide the date on which you were married or entered into the commonlaw relationship:

Have you previously been married or in a common-law relationship?

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Children (including stepchildren and children of your spouse/ commonlaw partner). Family name, given name, and age:
1.
2.
3.

Have you or your family members ever committed, been arrested for, or
been charged with or convicted of any criminal offence in any country?

Do you or your family members have any physical or mental disorders?

APPLICANT
Number of years of education in total:(school, college, university)
15

Education: please indicate all educational institutions you have attended, school/facility
names, duration of studies (from month/year to month/year), field and level of study
(Bachelors degree, Masters degree, PhD)
Frsineti Gymnasium- from 1.09.2001 to 31.05.2009;
Ellada high-school, from 1.09 2009 to 11.07.2012;
Stefan cel Mare University of Suceava (Romania), from 1.10.2012 to 19.07.2015,
bachelor studies in the field of International Relations and European Studies.
Karadeniz Technical University of Trabzon (Turkey), Erasmus program, from 24.09.2013 to
14.01.2014

Work experience: duration (from month/year to month/year), company name,

occupation, main responsibilities, people management experience.
15.06.2014-10.10.2014 - Summer Work and Travel Program in USA, Grand View Lodge
Nisswa, Minnesota.
Front desk receptionist.
Additional information: certifications, professional development courses.

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Your current level of English/French

English
Level:

Speakin
g

Listening

Reading

Writin
g

Speakin
g

Listening

Reading

Writin
g

Advanced
Can clearly and spontaneously express his/her
opinion on a wide variety of subjects
Intermediate
Can express his opinion and communicate
effectively in familiar social situations regularly
encountered in work, school, leisure, etc.
Basic
Can understand and use familiar everyday
expressions and very basic phrases. Can
communicate in simple and routine tasks
requiring a direct exchange of information on
familiar and routine matters
None

French
Level:
Advanced
Can clearly and spontaneously express his/her
opinion on a wide variety of subjects
Intermediate
Can express his opinion and communicate
effectively in familiar social situations regularly
encountered in work, school, leisure, etc.
Basic
Can understand and use familiar everyday
expressions and very basic phrases. Can
communicate in simple and routine tasks
requiring a direct exchange of information on
familiar and routine matters
None

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SPOUSE
Education: please indicate all educational institutions you have attended, school/facility
names, duration of studies (from month/year to month/year), field and level of study
(Bachelors degree, Masters degree, PhD)

Work experience: duration (from month/year to month/year), company name,

occupation, main responsibilities, people management experience.

Additional information: certifications, professional development courses.

Current level of English/French

English
Level:

Speakin
g

Listening

Readi
ng

Writing

Speakin
g

Listening

Readi
ng

Writing

Advanced
Can clearly and spontaneously express his/her
opinion on a wide variety of subjects
Intermediate
Can express his opinion and communicate
effectively in familiar social situations regularly
encountered in work, school, leisure, etc.
Basic
Can understand and use familiar everyday
expressions and very basic phrases. Can
communicate in simple and routine tasks requiring
a direct exchange of information on familiar and
routine matters
None

French
Level:
Fluent
Can clearly and spontaneously express his/her
opinion on a wide variety of subjects
Intermediate
Can express his opinion and communicate
effectively in familiar social situations regularly
encountered in work, school, leisure, ect.
Basic
Can understand and use familiar everyday
expressions and very basic phrases. Can
communicate in simple and routine tasks requiring
a direct exchange of information on familiar and
routine matters
None

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Your Future Plans in Canada

In which Province/City in Canada would you like to live and why:

Do you have any relatives, friends or acquaintances in Canada? If yes, where

do they reside and what do they do for living?
No

What are your and each of your family members career and educational
goals in Canada?

Additional Information.
Please provide any additional information which you think might be useful to better understand
your family situation and your goals in Canada.

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