Immigration Assessment Form

1 - Personal Information
Name: MANGESH D SARAF
Date of Birth : 14/3/1984

Sex (Male/Female): MALE

Contact Number: +919823427479

Email: sarafmangesh@yahoo.com

2 - Family Composition
Present marital Status: Married
Number of Children with Age: 1, 3 years 6 months Old

3 –Duration
Education
(please Academic &
include the month and Marks Name of School/University with
year) Professional
From To Obtained country
Qualification
Sept Aug BE (Electrical 61% PES College of Engg, Dr.Babasaheb
2002 2006 Electronics & Ambedkar Marathwada University,
Power Engg) India
July Jun- Diploma In 68% Government poly- technique
1999 2002 Electrical Engg Auranagbad (India)
4 - Work History
Total number of years of experience with complete history of past 10 years:
Duration(please include the Name of the
month and year) Designation and Job Profile
From To Company
Jan Present Reliance Dy. Manager-Materials & Contracts
2016 Corporate IT
Park Limited
April- Jan- Osborn India Asst.Manager-Sourcing & Procurement
2012 2016 Pvt Limited
April March- Micriquale Sr.Executive -Purchase
-2011 2012 Limited
Oct-
2009

5 - Ability in Language – ENGLISH: (High/Moderate/Basic/None) Mention IELTS results

Reading Writing Speaking Listening
SPEAKING:
LISTENING:
READING:
WRITING:

6 - Ability in Language – FRENCH: (High/Moderate/Basic/None)

Reading Writing Speaking Listening
SPEAKING:
LISTENING:
READING:
WRITING:

Information on Spouse (Applicant’s Husband or Wife)

Name:
Date of Birth :
Sex (Male/Female):
7 – Education
Duration(please
include the month and Academic &
year) Marks Name of School/University with
Professional
Obtained country
From To Qualification

8- Ability in Language – ENGLISH: (High/Moderate/Basic/None) Mention IELTS results

SPEAKING:
LISTENING:
READING:
WRITING:

9 - Ability in Language – FRENCH: (High/Moderate/Basic/None)

SPEAKING:
LISTENING:
READING:
WRITING:
 10 - Work History of Spouse
Total number of years of experience with complete history of past 10 years:
Duration(please include the Name of the
month and year) Designation and Job Profile
From To Company

11: Any self-employed profession by applicant or spouse during last 5 years?

PERSENT ADDRESS:-
Name of Office:

Protection of personal information

The personal information appearing on this form, and in any documents that must be appended to it, is required for
processing your application for Immigration to Canada, Act respecting immigration to Canada, the Regulation respecting the
selection of foreign nationals, the Regulation respecting the immigration consultants and their administrative regulations.
Your personal information is confidential and may not be disclosed without your consent unless explicitly authorized by you.

DECLARATION

I declare that the information contained in this application and appended documents, if any, is complete and accurate and I
will notify the representative of any change in answers given on this form before the submission of application to
Immigration Department (CIC), CANADA.
I acknowledge that I have read the notice on the protection of personal information in the section above.
I further acknowledge that by saving this document and sending the same to my legal representative electronically,
constitute my consent to use the information and no physical signature is required.
I also agree that XIPHIAS Immigration will be making an initial assessment on the basis of the limited information provided
on this form.