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Form NTNP-01
OFFICE USE ONLY
File #:
Date Received for
Assessment by NTNP
YY/MM/DD
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Northwest Territories’ Nominee Program
NOMINEE INFORMATION FORM
• Please complete all sections of this form. If a question doesn’t apply please write “n/a”.
• If you have any questions or need help with the forms please contact the Coordinator, Immigration at 1-855-440-5450
or email [email protected].
Which Nominee Program stream are you applying under?
Critical Impact Worker
Express Entry
Skilled Worker
Self Employment
Entrepreneur
1. Personal Information
Given Name(s):
Last Name (family name):
Residential Address (Street):
City/Town:
Province/Territory:
Country:
Postal Code:
Mailing Address (if different from above):
City/Town:
Province/Territory:
Country:
Postal Code:
Telephone Number :
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Cell Number:
(
)
Email Address:
Date of Birth - YY/MM/DD:
Place of Birth (City and Country):
Gender:
¡¡Male ¡¡Female
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If you are currently in Canada, please indicate your immigration status:
¡¡Foreign Worker
¡¡Visitor
If you currently have a Temporary Work Permit, please indicate:
Client ID:
Citizenship (Country):
¡¡Student
Expiry Date:
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2. Previous Immigration to Canada
Have you ever applied for admission to Canada as an immigrant?
¡¡NO
¡¡YES If ‘Yes’, please provide more
information below
Immigration Office Contacted:
Dates of Application - YY/MM/DD:
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Province/Territory of Application:
3. Education Information (Include information on secondary school, technical training, college, university, etc.)
Name of Institution
NTNP - Nominee Information Form
Date Started
YY/MM/DD
Date Ended
YY/MM/DD
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Program
Certification Obtained
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4. Employment History (last 5 years including current employment)
Name of Institution
Date Started
YY/MM/DD
Date Ended
YY/MM/DD
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City/Country
Position
5. Language Proficiency
Do you use English or French in the Workplace?
¡¡English
¡¡French
Have you used English as the primary language of communication at school?
¡¡NO
¡¡YES
Have you studied English as a foreign language or as a second language?
¡¡NO
¡¡YES
6. Language Test Results (if applicable)
Which test did you take?
¡¡IELTS
¡¡CELPIP
Please Indicate your scores in each category:
¡¡TEF
Listening
Date of test - YY/MM/DD:
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Writing
Reading
Speaking
7. Family Information
List your immediate family members. Include spouse or common-law partner,
and any dependent children (19 years-old and under).
Passport Number:
Name:
Country of Birth:
Date of Birth - YY/MM/DD
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Name:
Gender:
¡¡Female ¡¡Male
Relationship to you:
¡¡Daughter
¡¡Spouse
¡¡Son
Passport Number:
¡¡Other:
Country of Birth:
Date of Birth - YY/MM/DD
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Gender:
¡¡Female ¡¡Male
Relationship to you:
¡¡Daughter
¡¡Spouse
¡¡Son
Passport Number:
¡¡Other:
Country of Birth:
Date of Birth - YY/MM/DD
/
/
Name:
Gender:
¡¡Female ¡¡Male
Relationship to you:
¡¡Daughter
¡¡Spouse
¡¡Son
Passport Number:
¡¡Other:
Country of Birth:
Date of Birth - YY/MM/DD
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/
Name:
Gender:
¡¡Female ¡¡Male
Relationship to you:
¡¡Spouse
¡¡Son
Date of Birth - YY/MM/DD
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Gender:
¡¡Female ¡¡Male
Name:
NTNP - Nominee Information Form
¡¡Daughter
Passport Number:
Relationship to you:
¡¡Spouse
¡¡Son
¡¡Daughter
¡¡Other:
Country of Birth:
¡¡Other:
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8. Nominee Applicant Declaration
This information is collected under the Northwest Territories Access to Information and Protection of Privacy Act section
40(c), will be used in the processing of my application, and will be protected by the privacy provisions of that Act. Applicants
have the right to examine and request correction of their records, and to request a review by the Information and Privacy
Commissioner. If you have any questions about the collection of information, please contact the Coordinator, Immigration
at 1-855-440-5450.
I authorize the Government of the Northwest Territories to share information relating to my/our application with Citizenship
and Immigration Canada and any other federal/provincial/territorial departments and their agencies, as well as municipal
governments, unions and associations and other appropriate organizations as deemed appropriate by the Government of
the Northwest Territories for the purposes of administering the program, including the verification and processing of my/our
application and for the purposes of program evaluation.
I declare that:
•I intend to live in the Northwest Territories on a permanent basis.
•I intend to accept the employment opportunity identified in this application.
•I agree to sign a Memorandum of Understanding that outlines my responsibilities under the Nominee Program.
•The information I have given in this application is truthful, complete and correct.
•I understand that any false statements or concealment of a material fact may result in my exclusion from the Nominee
Program and may be grounds for my prosecution and removal from Canada.
•I understand all the foregoing statements, having asked for, and obtained, an explanation for any point which
was not clear to me.
•I am not a Refugee Claimant.
X
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Nominee’s Signature (Mandatory)
/
Date - YY/MM/DD
X
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Signature of spouse or common-law partner (Mandatory)
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Date - YY/MM/DD
X
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Dependent children over 18 years of age (Mandatory)
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Date - YY/MM/DD
How did you hear about this program?
Employer
Professional Association
Career Development Officer
Union
Consulate/High Commission
Newspaper
Visa/Immigration Official
Poster
Government of Canada Website
Radio
Website (other):
Family/Friends
Multicultural Centre
Other:
Educational Institution (college, university)
Employment Centre
NTNP - Nominee Information Form
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