IMMIGROUP Consultation Intake Form In partnership with Immigroup, Doherty Fultz Immigration offers one-on-one consultations by video conference, phone, and in person to address your immigration questions. All consultations are with a licensed immigration consultant and last up to one hour. In order to book a consultation, we ask that you please complete the following form. After submitting the form, we will contact you to arrange an appointment. Full Name * Email * Phone * Street address * City/Town * Province/State * Zip/Postal * Gender * Date of birth * Highest level of education received * Have you taken a language test in the past 2 years? * IELTS CELPIP TEF None Have you already received an Educational Credentia0l Assessment? (Economic Immigration Only) * Yes No Not Applicable Occupation * Employer’s name * Nationality * Country of residence * Choose one Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Norway Northern Mariana Islands Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe Status in Canada Expiry Date In Canada (if applicable) Do you have a Spouse/Common-Law Partner? No Spouse Common-law partner Spouse/Partner’s Name (if applicable) Spouse/Partner’s Nationality How long have you been married or in a common-law relationship? Have you or your spouse ever been convicted of a criminal offence? No Yes Which type of immigration matter best describes what you wish to discuss during your consultation? * NEW Essential Worker PR – Temporary Resident to Permanent Resident Pathway PR Through Express Entry or other Economic Stream Family Sponsorship PR using either Economic or Family Streams Work Permit and/or LMIA Visitor Visa Study Permit Canadian Citizenship Other Please briefly describe you immigration matter so we can assist you * How did you hear about us? * Referred by a friend or family member Google search/maps/reviews Facebook Instagram Moving 2 Canada VisaWire Returning Client Other By typing my name, I hereby certify that this document is legally executed by the person named herein as the Client, and that I understand and acknowledge all of the above information to be true, correct, and complete. * Today’s Date * By signing above, I indicate that I understand I am obliged to pay a consultation fee of CAD$225 + HST (clients in Canada) or USD$225 (clients outside Canada) per hour of consultation over video conference or telephone, or CAD$450 + HST in person. I understand that in-person consultation fees must be paid at the time of appointment booking, and consultation fees paid are non-refundable for missed or cancelled appointments. I understand that all quotes given for services at the time of a consultation remain valid for 90 days as long as no circumstances discussed during the consultation change. I understand that, with the exception of correspondence received from IRCC, Doherty Fultz Immigration will not review application forms or supporting documentation during a consultation. In order to book an application review, a separate review form must be completed by the applicant. All information discussed or disclosed in the context of a consultation at Doherty Fultz Immigration is STRICTLY CONFIDENTIAL, and is bound by representative-client privilege. These terms and conditions shall be governed by the laws in effect in the Province of Ontario, Canada. Please be advised that Anthony Doherty (R510956), Cassandra Fultz (R514356), and Brooke Westcott (R708924) of Doherty Fultz Immigration Inc. (located at 2558 Danforth Avenue, Suite 202, Toronto, ON, Canada M4C1L3; Telephone: 416-827-8778; email: info@dfimmigration.ca ) are members in good standing of the Immigration Consultants of Canada Regulatory Council (ICCRC)/College of Professional Immigration Consultants, and as such, are licensed and regulated by this organization and are bound by its By-laws, Code of Professional Ethics, and associated Regulations. By signing this intake agreement, you acknowledge that any interaction with IRCC or CBSA undertaken by you without retaining an Doherty Fultz Immigration RCIC as a legal representative is done at your own risk, and Doherty Fultz Immigration accepts no responsibility for the outcome of any such interaction. Opt In Yes, I would like to receive emails about important immigration changes and new programs. I understand I can unsubscribe at any time, and that my contact information is completely confidential forever. If you are human, leave this field blank. Submit
416-827-8778 
