Application for Nomination (AINP 003) - Alberta

1 Application for Nomination ( ainp 003 ). Employer-Driven Stream The personal information provided on this form and attachments is collected under the authority of section 33(c), and managed in accordance with the Freedom of Information and Protection of Privacy Act. The information will be used for the purpose of administering the Alberta Immigrant Nominee Program. If you have any questions about the collection of this information, you can contact the Alberta Immigrant Nominee Program, Suite 940, ATB Place North Tower, 10025 Jasper Avenue, Edmonton, Alberta , Canada, T5J 1S6. Email: Fax: 780-427-6560.

2 A. Candidate Details File Number (office use): Candidate's family name: Candidate's given name(s): Candidate's Gender: Male Female Candidate's residential address: City / Town: Prov. / Terr. / State: Postal / Zip code: Country: Canada Candidate's mailing address: (check here if same as above). City / Town: Prov. / Terr. / State: Postal / Zip code: Country: Candidate's home phone: Candidate's cell phone: Candidate's work phone: Candidate's fax: Candidate's email: Candidate's date of birth: (yyyy/mm/dd). Language of Communication: Native Language Candidate's place of birth: (city or town).

3 English French Candidate's country of citizenship: Candidate's country of birth: Candidate's intended province or territory of residence in Canada: B. Citizenship and Immigration Canada (CIC) Application History Have you, your spouse/common-law partner, or any of your dependent children, already submitted an Application for permanent residence in Canada to Citizenship and Immigration Canada (CIC)? Yes No If Yes, respond to each of the following: Canadian visa office to which Application for permanent Date Application submitted: (yyyy/mm/dd). residence was already submitted: Status of Application : CIC File Number: Principal applicant: Intended province or territory of residence Application class/category: on CIC Application : Other Application class/category: ainp 003 (2014/06) ID # Page 1 of 7.

4 C. Candidate's Occupation and Education Current job title: Current wage or salary: Hourly Annual $ CAD. Name of employer: Candidate's address of employment: City / Town: Prov. / Terr. / State: Postal / Zip code: Country: Education History Do you have any formal education? Yes No Years of formal education: Level of education successfully completed: (check all that apply). Doctorate / PhD Diploma (2 years) Secondary school Master's Degree Certificate (1 year) Other: (specify below). Bachelor's Degree Trade Certification/Apprenticeship Industry and Association Standards required and obtained: Alberta Apprenticeship and Industry Association of Professional Engineers and Geoscientists of Training (AIT) Alberta (APEGA).

5 Journeyperson Certification Certification in Workplace Hazardous Materials Information System (WHMIS). College of Physicians and Surgeons of Alberta Other standards required and obtained (specify below): College and Association of Registered Nurses of Alberta (CARNA). Work History Total years of employment: List all employment since age 18 that is relevant to the job for which you are submitting this Application : (add extra lines if necessary). From (date): (yyyy/mm) To (date): (yyyy/mm) City: Country: Name of Employer: Occupation: From (date): (yyyy/mm) To (date): (yyyy/mm) City: Country: Name of Employer: Occupation: ainp 003 (2014/06) ID # Page 2 of 7.

6 From (date): (yyyy/mm) To (date): (yyyy/mm) City: Country: Name of Employer: Occupation: D. Family Members Are you including a spouse or common-law partner who will accompany you to Canada? (do not include Canadian Citizens or permanent residents) Yes No Family name: Given name: Date of birth: Gender: (yyyy/mm/dd). Spouse or Male common-law partner Female Candidate's Spouse/Common-Law Partner's Occupation and Education Current job title: Number of years worked in Canada: Education History Do you have any formal education? Yes No Years of formal education: Level of education successfully completed: (check all that apply).

7 Doctorate / PhD Diploma (2 years) Secondary school Master's Degree Certificate (1 year) Other: (specify below). Bachelor's Degree Trade Certification/Apprenticeship Are you including any dependent children who will accompany you to Canada? (Please refer to the CIC's website for the current definition of dependent. Do not include Canadian Citizens or permanent residents) Yes No Family name: Given name: Date of birth: Gender: (yyyy/mm/dd). Male Dependant Female Male Dependant Female Male Dependant Female E. Background in Canada and Alberta List each person living in Canada who is related to you or your spouse/common-law partner: (add extra lines if necessary).

8 Name of Relative: Relationship: City / Town: Province / Territory: Years spent in Canada: ainp 003 (2014/06) ID # Page 3 of 7. Name of Relative: Relationship: City / Town: Province / Territory: Years spent in Canada: Name of Relative: Relationship: City / Town: Province / Territory: Years spent in Canada: List any visits you have made to Canada, before you completed this form, where you had entered and then departed: (add extra lines if necessary). Reason for visit: Province / Territory visited: Year/Month entered: (yyyy/mm) Year/Month departed: (yyyy/mm). Reason for visit: Province / Territory visited: Year/Month entered: (yyyy/mm) Year/Month departed: (yyyy/mm).

9 Reason for visit: Province / Territory visited: Year/Month entered: (yyyy/mm) Year/Month departed: (yyyy/mm). F. Document Checklist The document checklist specific to this category can be found on our website: Employer-Driven Skilled Worker Category and International Graduate: Employer-Driven Semi-Skilled Worker Category - #2. I have attached all required and supporting document outlined in the document checklist: Yes No G. Marketing How did you learn about the AINP? (check all that apply). Alberta promotional material Immigrate to Alberta Information Service Other: (specify below).

10 AINP website Recruitment agency Family member Alberta government webinar ainp 003 (2014/06) ID # Page 4 of 7. H. Program Evaluation AINP will be contacting you in the future for follow-up. Please provide the name of an additional contact person, preferably in Canada, who we may contact if we cannot reach you. Do not list your authorized representative, your spouse/common-law partner or your employer. Family Name: Given Name(s): Phone number of contact person: Email of contact person: I. Use of a Representative I have used a representative or third party in connection with this Application to the AINP.