Diverse Immigration Services Info Collection Form

Applicant Information:

Name: MOHIT BHADAURIA

Date of Birth: 06-07-1989
Mobile No.: 9300052280
Contact No.: 9300052280
Email: mohitbhadauria@outlook.in
Marital Status: MARRIED
Going Alone / With Family: Alone
Total Experience (In years): 8 years
Current Address: 432-B ANAND NAGAR, GWALIOR, MADHYA PRADESH

Permanent Address: 432-B ANAND NAGAR, GWALIOR, MADHYA PRADESH

Educational Qualification: Mention the commencement & conclusion, month & year.

From Till Aggregate Regular /

College / University Program
MM YY MM YY % age Correspondence
200 201
07 06 RGPV B.E 65.7 REGULAR
6 0

Work Experience Details: Begin with the current job & designation. If working in the same organization on
different designations mention the duration of each designation. Also, specify if it was full time or part time.

From Till Full Time /

Firm, Organization, Company Designation
MM YY MM YY Part Time

Language Skills Details: Please tick (√) the appropriate column and indicate your ability to communicate.

English High Moderate Basic No French High Moderate Basic No

N
Speaking Y Speaking N
Reading Y Reading N
Writing Y Writing N
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 Diverse Immigration Services Info Collection Form
Listening Y Listening N

Overseas Work Experience: Did you or your spouse ever worked full time and completed a year or more either
in Canada, Australia, New Zealand or Singapore?

From Till Full Time /

Name of the Employer Country Designation
MM YY MM YY Part Time

Overseas Study History: Did you or your spouse ever completed two years of full time Post Secondary study
either in Canada, Australia, New Zealand or Singapore? If yes, please mention the following information in the
column:

Certificate /
From Till Full Time /
Name & Country of the Institute Course Pursued Diploma /
MM YY MM YY Part Time
Degree

Financial Details:

CTC (Annual Income)

Medical Details: Do you, your spouse or children have any serious medical problem? If yes, please mention the
details in the column.

Name Medical Description

Dispute / Illicit Details: Is there any Civil / Police Complaint / Criminal Case pending against you or your spouse?
Please mention YES / NO: _____________

Children Details: Please mention the details of your child / children below:

Full Name Date of Birth

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 Diverse Immigration Services Info Collection Form

Spouse Information:

Name:
Date of Birth:
Mobile No.:
Contact No.:
Email:
Current Address:

Permanent Address:

Educational Qualification: Mention the commencement & conclusion month & year.

From Till Aggregate Regular /

College / University Program
MM YY MM YY % age Correspondence

Work Experience Details: Begin with the current job & designation. If working in the same organization on
different designations mention the duration of each designation. Also, specify if it was full time or part time
work.

From Till Full Time/

Firm, Organization, Company Designation
MM YY MM YY Part Time

Language Skills Details: Please tick (√) the appropriate column and indicate your ability to communicate.

English High Moderate Basic No French High Moderate Basic No

Speaking Speaking
Reading Reading
Writing Writing
Listening Listening

3
Contact No.: +91 9999408064 ● Email: info@dimsindia.com
 Diverse Immigration Services Info Collection Form
Declaration by the Applicant: I declare that all the information given above is complete, correct & certifiable.

4
Contact No.: +91 9999408064 ● Email: info@dimsindia.com