Citizenship Application Assessment Form All information submitted is kept strictly confidential. View Privacy Policy A. PERSONAL DETAILSFull Name*Email Address*Phone Number*Gender*MaleFemaleAddress*City*State/Province*Zip/Postal Code*Place of Birth*Date of Birth*(If the calendar icon does not work, please manually enter the date using YYYY-MM-DD format)Citizenship*Country of Residence*Number of Children*Marital Status*Please selectSingle / Never MarriedMarriedDivorced / WidowedCommon LawConjugal Relationship Are you a permanent resident of Canada?*YesNoWhen did you obtain permanent residence?*(If the calendar icon does not work, please manually enter the date using YYYY-MM-DD format)Prior to obtaining permanent residence, were you a temporary resident in Canada?*YesNoDuring what period were you a temporary resident?*Have you physically resided in Canada for at least 3 years in the past 5 years?*YesNoHow many days have you been in Canada in the last 5 years?*How often have you travelled out of Canada in the past five years*Please selectDid not travelOccasionallyFrequentlyWhat countries have you travelled to in the past 5 years?*Are you able to speak English or French*YesNoWhat language do you speak?*What level is your English or French at? *Please selectFluentModerateBasicNoneHave you been filing income tax returns in Canada for at least 3 of the past 5 years?*YesNoB. APPLICANT ADMISSIBILITYHave you been convicted of or are currently charged with a criminal offence in any country?*YesNoAre you currently under a removal order?*YesNoAre you imprisoned, on parole, or on probation?*YesNoHas your Canadian citizenship previously been revoked?*YesNoHave you been convicted of human rights violations, war crimes or crimes against humanity, acts of subversion, espionage, or terrorism? *YesNoIf you have replied “yes” to any of the above questions, please provide details:C. FINAL DETAILSIf there is anything else that you believe is important in relation to your case please note it here:DECLARATIONI certify that the above information provided by me in the Free Assessment is true and I agree to Matthew Jeffery's Privacy Policy & Use of Terms.*Yes, TrueFurthermore, I consent to the law office of Matthew Jeffery, Barrister & Solicitor, contacting me in relation to the above Free Assessment.*YesSendThis field should be left blank