Refugee Claimant Questionnaire

Name *

Name

First

Last

Email *

Current residential address: *

Current residential address:

City

State/Province

Zip/Postal

Country

For how long have you been residing at the following address? *

Country of birth: *

Citizenship(s)? *

Do you have a valid visa to Canada? *

Yes

No

Do you have any family members living in Canada? *

Yes

No

If yes, what are their names, relation to you, and status in Canada?

Why are you afraid to stay (or go back) to your home country? Please provide a brief description. *

Have you ever had a US visa? *

Yes

No

Do you currently hold a valid passport? *

Yes

No

When does it expire? *

Do you have scanned copies of all your past passports?

Yes

No

Have you previously traveled to other countries? If yes, please list location and dates:

Do you have supporting documents to support your claim of risk in your home country? (Ex. Police reports, medical reports, affidavits, letters, etc.) *

Yes

No

Did you try to seek help from the local authorities? *

Yes

No

Did you try to live in another safe location in your country? *

Yes

No

(FIX) Have you ever had any criminality in your country? If so, please advise and we will provide you with the criminality questionnaire to complete. *

Yes

No

Have you ever submitted any applications to Canada? *

Yes

No

If so, what was the outcome? *

Have you ever had any refusals related to any Canadian immigration applications? *

Yes

No

What was the date of the refusal?

Have you ever had any issues at the border? *

Yes