Assessment for Refugee Status Seekers
This Assesment Form will provide us essential information to assist you with your refugee application
Contact Information
Ms. Mr.
Family Name:
First Name:
Email Address:
We will send response to this e-mail. Make sure it is correct!
Day time Telephone Number:
Please include country code, city code, etc.
Refugee Applicant
Name of principal applicant:
(if different from contact person)
Marital Status:
Number of children and/or dependants:
Country(ies) of Citizenship:
City and country where you
are currently residing:
Please indicate your abilities in both the English and French languages, as follows:
   Very good command of the language in a range of 
        social and work situations, and no difficulty 
        communicating in a professional capacity. 
   Can communicate reasonably well about personal 
        and familiar things. 
   Command of just a few basic words.
Reading Writing Speaking Listening
Have you previously sought refugee status in Canada or applied for an immigrant or visitor visa?
Yes No
If yes, please explain:
Have you been refused refuge status in, or immigrant or visitor visa to Canada or any other country?
Yes No
If yes, please explain:
Are you in your country of citizenship or habitual residence? Yes No
If no, please explain:
Have you ever applied for convention refugee status with the United Nation high commissioner for refugees.(UNHCR)? Yes No
If yes, please explain:
Have you been refused refugee status by the country in which you are currently living in or in any other country? Yes No
If yes, please explain:
Can you build a life in the country in which you are now located? Yes No
Please explain:
Are you in danger in the country where you are now living? Yes No
Please explain:
Will you be able to return to the community you are fleeing? Yes No
Please explain:
Have ever been detained or put in Jail? Yes No
If yes, please explain:
Have you ever been associated with any organizations, such as political, social or any other organizations. Yes No
If yes, please explain:
Why do you consider your-self as a refugee? Please explain:
An automated response acknowledging receipt of your form will be emailed to you immediately. If you do not receive the acknowledgment, it could mean that the email address provided by you is invalid and we will be unable to respond to your assessment request.