NSNP 100 – Application Form (FEBRUARY 2014) Page 1 of 7

Nova Scotia Nominee Program

NSNP 100 – Application Form for the Principal Applicant

Please refer to the Nova Scotia Nominee Program Application Guide for the category to which you are applying when

completing this application. Please ensure that all documents requested in the Application Guide are included with your

application. Incomplete applications will not be processed.

Section A – Nova Scotia Nominee Program Stream

I am applying to the following stream of the Nova Scotia Nominee Program:

Skilled Worker Regional Labour Market Demand Family Business Worker

Community Identified

Section B – Personal Information Family name: Given name: Date of birth (dd/mm/year): Principal applicant’s full name in native language: Spouse, common-law or conjugal partner Family name: Given name: Date of birth (dd/mm/year): Mailing address (do not use a representative, consultant, or lawyer’s address for street address or contact information)

street address city, town or village country postal code

Telephone number(s) – land line and cell:

Country code Number

Email address:

Criminal Record

Have you or any of your dependents ever been convicted of or charged with an offence in Canada or in any other country? Yes No If yes, please explain:

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Section C – General Information

How did you learn about the Nova Scotia Nominee Program?

Nova Scotia Office of Immigration Website Employer

Canadian visa office Nova Scotia promotion material

Immigration job fair or event overseas (please specify place and date):

Other (please specify):

Where do you intend to live (city/town/region, province): Assistance in completing the application Did you have help preparing your immigration forms? Yes No

If yes, who provided this assistance (please specify the name of the individual)

Employer: Lawyer:

Immigration consultant: Other:

Note: An authorized, paid immigration representative must be a member in good standing of either the Immigration Consultants of Canada Regulatory Council (ICCRC), a Canadian provincial or territorial law society, or the Chambre des notaires du Québec. For more information on immigration representatives and who may represent you, please visit www.cic.gc.ca/english/information/representative/rep-who.asp

Section D – Application History

Have you or a family member accompanying you, previously been approved, refused or have made applications for admission to Canada as an immigrant (permanent resident or refugee claimant)? Yes No

If yes, complete the following: Applicant’s full name: Family name Given name

Federal category of application(s):

Federal Skilled Worker Entrepreneur

Canadian Experience Investor

Family Class Self-employed

Refugee Other (please specify):

Provincial Nominee Program

If you applied through a Nominee Program, please indicate the province or territory of application and specific stream:

Date of application (dd/mm/year):

Citizenship and Immigration Canada (CIC) file number or Provincial Nominee file number:

Result (in-process, approved, refused, etc.):

Intended destination in Canada:

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Section E – Language Ability

Language Skills (self-assessment)

English Read Speak Write Listening

Fluent

Well

Basic

None

French Read Speak Write Listening

Fluent

Well

Basic

None

If your first language is not English or French, you need to demonstrate that you can communicate comfortably in English or in French in familiar social and work situations. Please explain how you meet these criteria and attach relevant documentation as per the application guide (e.g. language tests, primary language of communication at work or at school, work, etc.):

Section F – Nova Scotia Connections

Do you or your spouse, common-law or conjugal partner have relatives living in Nova Scotia or in Canada? Yes No

If yes, provide details below of your relatives living in Nova Scotia and Canada:

Name of relative

(family name, given name)

Town/city and province Telephone Relationship (e.g. sister) Years in Canada

Have you or your spouse, common-law or conjugal partner lived or visited Nova Scotia or Canada? Yes No

If yes, describe each of the stays in Nova Scotia or Canada by you or your spouse, common-law or conjugal partner or dependents:

Who visited NS or Canada? Who did you visit?

Dates (dd/mm/year) Province(s) visited Reason for visiting (e.g. vacation, business)

Section G – Education in Nova Scotia

Have you or your spouse, common-law or conjugal partner studied in Nova Scotia? Yes No

If yes, complete the following indicating who was studying:

Name From mm/year To mm/year Name of Institution City Course, degree, certificate

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Section H – Employment in Nova Scotia

Do you have an offer of employment? Yes No Not applicable

Name of employer/company:

Address of employer/company:

Your position title:

Offered salary:

If you do not have an employment offer, what is your intended occupation?

Has the principal applicant worked in Nova Scotia? Yes No

If yes, complete the following:

From mm/year To mm/year Occupation Name of employer City of employment

Has the spouse, common-law partner or conjugal partner or any dependents worked in Nova Scotia?

Yes No If yes, complete the following:

From mm/year To mm/year Occupation Name of employer City of employment

In your own words, tell us briefly about your settlement in Nova Scotia and any future plans you may have.

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Section I – Financial Information

You must present the most up-to-date financial documents to support all the information provided in this statement.

Please indicate all exchange rates used:

1.00 ___________________ = _____________ CAD $ Date of exchange rate ___________________________

(identify your currency) 1 CAD $ = ________________________________ Date of exchange rate ____________________________ (identify your currency)

A. Assets List all assets in Canadian dollars including the value of any property owned by the principal applicant and all accompanying dependent family members. Do not include the value of jewellery, vehicles and other personal assets. Use extra paper if necessary.

Description of assets (bank accounts, real estate, investments, pensions, etc.) $ Amount

Total assets (add all amounts above) $

B. Liabilities (all debts) List all liabilities in Canadian dollars including mortgages, bank loans, personal loans, lines of credit and credit cards balances.

Description of liabilities (mortgages, loans, credit cards balance, etc.) $ Amount

Total liabilities (add all amounts above) $

C. Net worth

Total assets minus total liabilities (A – B = C) $

Alimony and child support

Do you or your spouse, common-law partner or conjugal partner have any financial or legal responsibility towards children from a previous relationship?

Yes No If yes, complete the following and provide supporting documents:

Name of child and date of birth (dd/mm/year):

1. ________________________________________________________________________________________

2. ________________________________________________________________________________________

3. ________________________________________________________________________________________

Description of responsibility: ________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

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Section J – Authority to Collect and Disclose Information and Applicant Declaration

This information release and declaration must be signed by the principal applicant and all accompanying dependent family members 18 years or older, authorizing the Government of Nova Scotia to collect, use, retain, disclose, and destroy personal information to assess your application to the Nova Scotia Nominee Program and to research, monitor, and evaluate the Program under the authority of the Nova Scotia Freedom of Information and Protection of Privacy Act and other relevant provincial legislation, the Immigration and Refugee Protection Act and Regulations and other relevant Government of Canada legislation. If you have any questions about the collection of personal information, please contact the Nova Scotia Office of Immigration. I authorize immigration officials with the Government of Nova Scotia and the Government of Canada to disclose, and collect, as necessary, all personal information contained in my application for the Nova Scotia Nominee Program and my federal immigration application regarding myself or any dependent member of my family for the purpose of assessing my application, verifying information in this application, and evaluating the Nova Scotia Nominee Program. I authorize the Government of Nova Scotia to disclose and collect all personal information collected by and disclosed as part of my application for the Nova Scotia Nominee Program to other parties in Nova Scotia and elsewhere to assess this application. I understand that the Government of Nova Scotia may contact such parties to verify information provided by me in this application. I understand that I have the right to examine and request corrections or amendments to my personal information, whether held by a provincial or federal government office. I consent to the Government of Nova Scotia collecting any personal and other information, including information about my address(es), telephone number(s), social insurance numbers, marital status, employment, income, assets, liabilities, benefits received under other provincial and federal government programs or any other relevant personal information, required as part of my involvement in the Nova Scotia Nominee Program and to locate and contact me about evaluating the program and my participation in it. I consent to the Government of Nova Scotia collecting this information from any federal, provincial, municipal or other local authority or any other person, department, agency or organization holding such information. Signature of principal applicant Signature of spouse, common-law or conjugal partner Signature of dependent over 18 years old Signature of dependent over 18 years old Signature of dependent over 18 years old Signature of dependent over 18 years old Date

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Declaration of Principal Applicant and Spouse, Common-law or Conjugal Partner

I declare that the information I have given in this application truthful, complete and correct. I understand that any false statement or concealment of information may result in Citizenship and Immigration Canada and/or the Government of Nova Scotia refusing my application or, if applicable withdrawing my nomination and/or my Canadian permanent residence visa. I understand that my failure to provide a complete application package including all required forms and credible, supporting documentation may result in the return or refusal of my application. I intend to settle in the Province of Nova Scotia upon arrival in Canada. I declare that I agree to provide the Nova Scotia Office of Immigration with my contact information (current address, phone number(s), email) within 30 days of arriving in Canada and to inform the Nova Scotia Office of Immigration of any change of address or phone number(s) or email for a period of 3 years after arriving in Canada. I understand all the statements for the authority to collect and disclose personal information and this declaration, and have asked for and received an explanation on every point that was not clear to me. _______________________________________________ _____________________________________________ Signature of principal applicant Signature of spouse, common-law or conjugal partner ____________________________________________________ __________________________________________________ Signature of dependent over 18 years old Signature of dependent over 18 years old ____________________________________________________ __________________________________________________ Signature of dependent over 18 years old Signature of dependent over 18 years old ____________________________________________________ __________________________________________________ Signature of witness Full name of witness (family name, given name)

_______________________________________________ ______________________________________________ Relation to principal applicant Signed at (city/town and country)

_______________________________________________ Date (mm/dd/year) Nova Scotia Office of Immigration 1741 Brunswick St., Suite 110A P. O. Box 1535 Halifax, Nova Scotia CANADA Tel: (902) 424-5230; Fax: (902) 424-7936; email: nsnp@gov.ns.ca Website: www.novascotiaimmigration.com