First Name

Last Name

Address Line

Country

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State

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City or District

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Phone

Email

Company name

Website

Date Started & Ended

Brief Description of Duties

Annual sales (approx.):

Total number of employees:

Job Title (NOC Code, if known)

SelectNOC 00NOC ANOC BNOC CNOC D

% Shares owned incl. family:

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1. How much would you be willing to invest?

Select$100,000 CDN$100,000 to $200,000$200,000 to $500,000$500,000 to $1 Million$1 Million to $2 MillionOver $2 MillionOther amount

2. When do you want to come to Canada?

3. Canadian friends, relatives, and associates: Do you have any potential partners, relatives or friends in Canada to help you with your business?

YesNo

4. Would you be able to stay and live in Canada for at least 50% of the year to manage your business? Or more?

YesNo

5. Do you have any criminal record?

YesNo

6. Do you have any serious medical condition?

YesNo