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Application for Selection Certificate
Principal Applicant – Spouse or de facto spouse

INSTRUCTIONS
How to complete this form Answer all questions accurately. If you run out of space, please finish your answer on a separate sheet marked with the number of the section of the form to which it refers. Who is required to fill out this form? The principal applicant and the accompanying spouse or de facto spouse, if any, who are applying under one of the following subclasses (definitions on page 2): • skilled worker; • self-employed worker or entrepreneur; • foreign national in a particularly distressful situation, within the meaning of section 18c of the Regulation respecting the selection of foreign nationals: this subclass does not include refugees, persons in a similar situation, nor protected persons. Dependent children accompanying you who are aged 22 or older or who are married or de facto spouses must complete the form Application for Selection Certificate – Dependent child aged 22 or older or who is married or a de facto spouse (definitions on page 2). A child who is not a dependent must fill out this form as a principal applicant. Appendices, supporting documents and place of application submission You must send this form, along with the appendices and the necessary supporting documents to the immigration office responsible for files originating in your country. Closely examine the list of documents to append to your application for a selection certificate, based on your country of residence at www.immigration-quebec.gouv.qc.ca/en/biq/index.html if you are applying under the skilled worker subclass or at www.immigration-quebec.gouv.qc.ca/en/forms/index.html if you are applying under the self-employed worker or entrepreneur subclass. For more information on immigration to Québec, please consult the website of the Ministère de l’Immigration et des Communautés culturelles at www.immigration-quebec.gouv.qc.ca/en/index.html. To access the pages of the office that covers your country, select your country of residence on the website of the Ministère. Payment of fees Fees must be paid when your application is filled. A variety of payment methods are accepted by the Ministère. They also vary depending on your country of residence. For information on this subject, select your country from the drop-down menu on the following page: www.immigration-quebec.gouv.qc.ca/en/immigrate-settle/permanent-workers/official-immigration-application/costimmigrating/fees-payment.html. Questions 8 and 8.1: Education – Indicate the name of the diploma or, failing that, the certificate of the last school year successfully completed. If you are studying in Quebec towards a diploma granted by a legally authorized Quebec institution, give the name of the diploma and the expected completion date of these studies. – Indicate if any of the diplomas mentioned are among the choices presented in Section 8.1. For more information on mutual recognition agreements (MRA), consult the site: www.immigration-quebec.gouv.qc.ca/fr/biq/paris/entente-france-quebec/index.html. Question 9: Work experience Indicate full-time or part-time work experience acquired through remunerated employment over the past five years, including military service and a youth exchange program (ex.: working holiday program). Include full-time or part-time remunerated or non-remunerated work terms completed over the past five years during apprenticeship, training or specialization that led to a diploma. Questions 11 and 11.1: Language skills To speed up the processing of your application, enclose with it an attestation for assessing french language knowledge – either a Test d’évaluation du français adapté pour le Québec (TEFaQ) or a Test de connaissance du français pour le Québec (TCFQ). You may also submit the results of any of the following tests: the Diplome d’études en langue française (DELF), the Diplome approfondi
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Ministère de l’Immigration et des Communautés culturelles

de la langue française (DALF), the Test de connaissance de français (TCF) or the Test d’évaluation du français (TEF). If you choose the TCF or TEF, you must enclose the results of both the compulsory test and the optional test. You can learn what centres give these tests from the following links: • TCFQ, TCF, DELF and DALF tests: www2.ciep.fr/tcf/centres/liste.aspx • TEFaQ and TEF tests: www.fda.ccip.fr/tef/centres Question 18: Preliminary Evaluation for Immigration (PEI) The Preliminary Evaluation for Immigration enables you to obtain directly online a free summary evaluation of your chances of being selected by Québec. Note that this does not, however, lead to a formal decision, but rather provides you with a positive or negative opinion regarding your candidacy. You can do this evaluation starting on the next page: www.form.services.micc.gouv.qc.ca/epi/index.jsp?languageCode=en. Question 19: Use of the services of a paid individual The forms and instructions were designed to enable persons wishing to immigrate to Québec to fill out the forms without help. It is therefore not necessary to use the services of a paid individual to handle your immigration process. The Ministère de l’Immigration et des Communautés culturelles does not give priority or special treatment to applications from individuals who retain the services of a paid individual. All applications are treated equally. If you decide to retain the services of a paid individual, be advised that the Ministère, to better protect applicants against dubious or illegal practices, deals only with: – members in good standing of the Barreau du Québec or the Chambre des notaires du Québec; – persons with a special authorization issued by the above organizations; – immigration consultants recognized by the Ministère de l’Immigration et des Communautés culturelles and entered in the Registre québécois des consultants en immigration. To find out if an immigration consultant is recognized by the Ministère, consult the Register at the following address: www.micc.gouv.qc.ca/consultant. If you use the services of an immigration consultant to advise you, help you or represent you in the framework of this application, you must notify the Ministère and identify this person. Do not forget to give your personal residence address along with that of the person who advises you, assists you or represents you. Power of attorney: if you want someone to represent you in your dealings with the Ministère, you must send an original power of attorney, signed by you and this person, to the office responsible for handling your application. Common values of Québec society Québec welcomes immigrants with their know-how, skills, language, culture and religion. Québec provides services to help them integrate and participate fully in Québec society. Integrating in Québec society means being prepared to learn about and to respect its common values. Please consult information on the common values of Québec society at: www.valeurscommunesduquebec.gouv.qc.ca. Section photographs The principal applicant must enclose photographs of himself, his accompanying spouse or de facto spouse and their accompanying dependent children. If the spouse or de facto spouse is filling out the form, he or she needs only to attach his own photograph. Signatures It is very important to sign this form in the places indicated. Otherwise, the file will be returned to you. • Common values of Québec society: The “Common values of Québec society” section on Page 6 must be signed by the applicant and by any accompanying dependent children aged 18 or older. • Declaration: The Declaration section on Page 7 must be signed by the principal applicant and accompanying spouse or de facto spouse, if any. • Declaration by spouse or de facto spouse: Married or de facto spouse applicants must fill out the “Declaration by spouse or de facto spouse” appendix at the end of the form.

Ministère de l’Immigration et des Communautés culturelles

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DEFINITIONS
Family member – a spouse or de facto spouse, who must be at least 16 years old; – a dependent child and, if applicable, that child’s dependent child. Spouse A married person who is at least 16 years of age, and who: – was not the spouse of any other person on the marriage date; – is not de facto spouse of any other person while living apart from his spouse for at least one year. De facto spouse A person who is at least 16 years old and who: – has been cohabiting for at least one year with an opposite-sex or same-sex partner who is at least 16 years of age; or – has had a conjugal relationship for at least one year with such a person but, since the person is being persecuted or the object of a certain form of penal control, cannot live with that person. Dependent child The biological offspring of either parent, who has not been adopted by any person other than their parent’s spouse or de facto spouse; or the adopted child of either parent. One of the following situations applies to this child: – he/she is less than 22 years old, and neither married (he/she is single, widowed, or divorced) nor a de facto spouse; or – he/she is still substantially dependent on the financial support of a parent, and - is 22 years of age or older, is studying full-time*, and is neither married nor a de facto spouse; or - became a spouse or de facto spouse before the age of 22, and is a full-time student*; or - is 22 years of age or older, and has been unable to support himself/herself at least since his/her 22nd birthday, owing to a physical or mental disability. This definition also extends to the child of a dependent child. * In order to be considered a full-time student, the child must be enrolled on a continuous basis in a postsecondary institution that is accredited by the relevant government authorities; must be attending this institution; and must have been actively taking academic, professional, or vocational training courses there on a full-time basis and without interruption at least since his/her 22nd birthday, or since the date on which he/she married or became a de facto spouse. Skilled worker Foreign national coming to settle in Quebec to hold employment he is likely able to hold. Entrepreneur Foreign national who: – Comes to Québec to create or acquire an agricultural, commercial or industrial corporation with the control, alone or together with his accompanying spouse or de facto spouse, of at least 25% of the equity, such percentage having a value of at least $100,000 CA. He must participate actively in its management and daily operations and in the case of a business or industrial enterprise, employ, on a permanent basis and for a minimum of 30 hours a week, at least one Québec resident, other than himself and family members accompanying him. – Has a minimum net worth of $300,000 CA, legally obtained, with his accompanying spouse or de facto spouse, if any. – Has at least two years experience in the operation of an entreprise in which he controls 25% of the equity, alone or with his accompanying spouse or de facto spouse. Self-employed worker Foreign national who: – Comes to Québec to create his employment by working in an occupation defined in the National Occupational Classification. – Has a minimum net worth of $100,000 CA, legally obtained, with his accompanying spouse or de facto spouse, if any. – Has at least two years experience working in the occupation or trade that he intends to practice in Québec.

Ministère de l’Immigration et des Communautés culturelles

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Application for Selection Certificate
Principal Applicant – Spouse or de facto spouse
I apply as: Principal Applicant Accompanying spouse or de facto spouse If you are applying in the economic immigration class, specify under which subclass: Skilled worker (regular program) Entrepreneur Self-employed worker 1. Identification Family name at birth First name

Date order received

Reserved for Administration Individual Reference No: File No:

Family name after marriage (if applicable)

Sex F M

Other names that you have used or by which you are known

Passport or identity card number

Date of birth Year Month Day

Place of birth City

Province / Region

Country

Citizenship

2. Present marital status (notify us immediately if your status changes; for the definition of de facto spouse, see definitions on the detachable page) Single Married De facto spouse Yes No Separated Divorced Marriage annulled Widowed

Have you been married more than once? 3. Residence address Number Street

App.

City

Province / Region

Postal code

Country

Mailing address, if different (give the name of the person living here if this address is not directly related to you)

Telephone no. Home

Telephone no. Work

E-mail address

Other (specify)

Fax no. Home

Fax no. Work

Other (specify)

4. Family members who may or may not be accompanying you in Québec. It is imperative that the principal applicant declare all the members of his family. (for the definition of family member, spouse, de facto spouse and dependent child, see definitions on the detachable page) Accompanying Family name First name Relationship Date of birth Place and country you at birth of birth Year Month Day No Yes

Ministère de l’Immigration et des Communautés culturelles

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5. Name and address of your dependent children (if different from your residence address) Name Address Country Telephone

6. Have you ever applied: For a temporary stay in Canada? No Yes Province Accepted For permanent immigration to Québec? No Yes Accepted Under which program? Regular program PEQ Province Accepted No Yes Province Accepted 7. List every place where you have lived in the past 10 years (use a separate sheet if necessary) Length of time From Year Month To Year Month City (number and street) Province / Region Country Denied Denied Date Waiting for a decision Denied Denied Other Date Waiting for a decision Date Waiting for a decision Waiting for a decision

For permanent residence in Canada (except Québec)? For refugee status in Canada?

No

Yes

8. Education, excluding elementary school (start with your most recent diploma) From Year 1 2 3 4 5 6 Year diploma obtained 1 2 3 4 5 6
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To Month Year Month

Name of institution / Country

Name of diploma obtained (see instructions on detachable page)

Specialization

Primary language of instruction

Ministère de l’Immigration et des Communautés culturelles

8.1 Are any of the diplomas entered under Question 8 Québec diplomas or their equivalent and found among these choices: Québec diploma Canadian diploma Diploma or training recognized as equivalent by a Québec regulatory body (except medical degree) Foreign diploma covered by a mutual recognition agreement (ARM) Other

____________________________________________________________

______________________________________________

9. Employment during the past 5 years, including military service (start with your most recent job; use a separate sheet if necessary) (see instructions on the detachable page) Experience 1 2 3 4 5 6 Job title Hours worked per week Primary language of work From Year Month Day Year From Month Day Name of company including your own and country where it is located (enter full name - no abbreviations)

Experience 1 2 3 4 5 6

9.1 Principal tasks you performed (starting with the last job; use an additional sheet if needed) Experience Job title — 1 — — — 2 — — — 3 — — — 4 — —
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Principal tasks performed as part of your duties

Ministère de l’Immigration et des Communautés culturelles

10. Stay in Québec over the last 10 years • for full-time studies • to work fulltime including a youth exchange program (ex.: working holiday program) • for business • other reasons (specify)

From Year Month Day Year

To Month Day Year

From Month Day Year

To Month Day

_________________ __________________________________

11. Language skills (see instructions in the detachable part) None Beginner French • Understand spoken • Ability to speak English • Understand spoken • Ability to speak 11.1 Are you submitting the results of a French test with your application? If so, which one? TCFQ TEFaQ TCF TEF DELF DALF other (specify) Yes 0 1 2 3 4 5

Intermediate 6 7 8 9

Advanced 10 11 12

No

___________________________________

12. Family in Québec (permanent residents or Canadian citizens residing in Québec) Relationship Family and first name Address in full Telephone no.

13. In which city or region of Québec do you plan to live?

14. Intended profession in Québec:

____________________________________________________________

____________________________________________________
This profession is connected with or related to (check, where appropriate, one or two responses): your field of study your professional experience If yes, has the employer submitted an official application to the Ministère de l’Immigration et des Communautés culturelles to validate this job offer made to you? Yes No

15. Have you received an offer of employment in Québec? Yes No

If yes, indicate the title of the employment along with the employer’s name and complete address:

16. Are you presently

a student

employed

unemployed

other (specify)

17. How did you learn about immigrating to Québec? (check one or more answers) Relatives or friends Information seminar given by the Québec government Educational world Professional association Web site, blog, or discussion group Advocate (lawyer) or immigration consultant Embassy or Government of Canada Québec employers News stories Advertising Montréal International
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Ministère de l’Immigration et des Communautés culturelles

18. Have you completed a Preliminary Evaluation for Immigration (PEI) before filling out this DCS? Yes No 19. Paid individual who advises you, assists you or represents you in the framework of your application Have you, in the framework of this application, retained a paid individual to advise, assist or represent you? If Yes, is the person: • a lawyer who is a member of the Barreau du Québec? • a notary who is a member of the Chambre des notaires du Québec? • a person holding a special authorization issued by the Barreau du Québec or the Chambre des notaires du Québec? • an immigration consultant? • another paid individual? If the person is an immigration consultant or another paid individual, give: Family name First name Yes Yes Yes No No No Yes Yes No No Yes No

Registration number (as it appears in the Registre québécois des consultants en immigration)

To find the consultant’s registration number, consult the register at the following address: www.micc.gouv.qc.ca/consultant

Photographs
Attach here a passport-sized photograph of yourself and accompanying family members (your spouse or de facto spouse, your dependent children or those of your spouse or de facto spouse, and any dependent child of those children).

Ministère de l’Immigration et des Communautés culturelles

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DECLARATION ON THE COMMON VALUES OF QUÉBEC SOCIETY
Québec is a pluralist society that welcomes immigrants who come from the four corners of the earth with their know-how, skills, language, culture and religion. Québec provides services to immigrants to help them integrate and participate fully and completely in Québec society in order to meet the challenges of a modern society such as economic prosperity, the survival of the French fact and openness to the world. In return, immigrants must adapt to their living environment. All Quebecers, whether they are native-born or immigrants, have rights and responsibilities and can freely choose their lifestyle, opinions and religion; however, everyone must obey all laws no matter what their beliefs. The Québec state and its institutions are secular; political and religious powers are separate. All Quebecers enjoy rights and freedoms recognized by the Charter of Human Rights and Freedoms and other laws and have the responsibility of abiding by the values set forth in them.

COMMON VALUES
The principal values set forth in this Charter, which are the foundation of Québec society, are as follows: Québec is a free and democratic society. Political and religious powers are separate in Québec. Québec is a pluralist society. Québec society is based on the rule of law. Women and men have the same rights. The exercise of human rights and freedoms must respect the rights and freedoms of others and the general well-being. Québec society is also governed by the Charter of the French language, which makes French the official language of Québec. Accordingly, French is the normal and usual language of work, instruction, communications, trade and business.

DECLARATION
UNDERSTANDING the scope and significance of the foregoing and AGREEING TO respect the common values of Quebec society, I DECLARE that I wish to live in Québec within the framework of and abiding by its common values, and that I want to learn French, if I do not speak it already.

Signature of the applicant

Date

Signature of the dependent child aged 18 or older

Date

Signature of the dependent child aged 18 or older

Date

Signature of the dependent child aged 18 or older

Date
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Ministère de l’Immigration et des Communautés culturelles

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 a selection certificate and the application of the Act respecting immigration to Québec, the Regulation respecting the selection of foreign nationals, the Regulation respecting the immigration consultants and their administrative regulations. This information may also be used by the Minister for the purposes of studies, statistics, program evaluation or to convey to you any information that might affect your application. Your personal information is confidential and may not be disclosed without your consent unless authorized by law. In particular, the law allows personal information to be communicated without your consent under certain conditions if such communication is necessary to: – – – – the application of an Act in Québec; the exercise of the rights and powers of an agency of the government of Québec or Canada, including federal immigration authorities; the purposes of a service to be provided to you by the Ministère or for performing a contract for services entrusted by the Ministère; prosecute an offence against an Act applicable in Québec, or because of the urgency of a situation.

Within the Ministère, access to this information is restricted to personnel who is qualified to receive personal information where such information is necessary for the discharge of his duties. With the exception of optional sections, any refusal to answer a question or any omission may result in the rejection of your application or may delay its processing. You may be informed about the information concerning you in the Ministère’s possession and, if applicable, request in writing that this information be corrected. For more information, contact the office that is processing your application. If this office is unable to provide you with the information requested, contact the departmental officer responsible for the protection of personal information at the Secrétariat général, Ministère de l’Immigration et des Communautés culturelles at the following address: Édifice Gérald-Godin, 360, rue McGill, 4e étage, Montréal (Québec) H2Y 2E9.

Declaration
I declare that the information contained in this application and appended documents, if any, is complete and accurate and I will notify the Ministère de l'Immigration et des Communautés culturelles of any change in answers given on this form within thirty (30) days of the change. I acknowledge that I have read the notice on the protection of personal information in the section above. I further acknowledge that: – I may have difficulty finding a job in Québec that matches my education or experience and that labour market conditions could change before I arrive in Québec. – The principal applicant is responsible for covering the financial costs associated with settling himself and any family members.

I understand that the Minister of Immigration and Cultural Communities may: – confirm, or have a third party confirm, the accuracy of information provided, and that I am breaking the law and am liable to a penalty if I give the Minister, an inquiry officer or reviewer any information that I know or should know is false or misleading with respect to an application for a selection certificate. – reject any application that contains false or misleading information or document. – refuse to consider an application for a selection certificate from a person who has provided false or misleading information or documentation within the past five years relative to an application under the Act respecting immigration to Québec. – cancel a selection certificate if the application contains false or misleading information or document, when the certificate was issued by mistake, or if the conditions required for the issue cease to exist.

In witness whereof, I have signed in
City / Country

Year

Month Day

Signature
Principal applicant Spouse or de facto spouse

Ministère de l’Immigration et des Communautés culturelles

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Appendix – Declaration by spouse or de facto spouse DECLARATION BY SPOUSE
Declaration of the principal applicant
I, the undersigned ____________________________________________________________

__________________________________, declare that I am the spouse of

_________________________________________________________.
First name and family name

First name and family name

Please indicate if the statements below correspond to your situation. Yes No At the time of my marriage to this spouse, I was married to another person. I have a de facto spouse, and have been living separated and apart from my spouse since In witness whereof, I have signed in
Year Month Day

____________________________________________________________

______ ,
City / Country Year Month Day

____________________________________________________________

________
Signature of the principal applicant

Declaration of the spouse accompanying the principal applicant
I, the undersigned ____________________________________________________________

__________________________________, declare that I am the spouse of

_________________________________________________________.
First name and family name

First name and family name

Please indicate if the statements below correspond to your situation. Yes No At the time of my marriage to this spouse, I was married to another person. I have a de facto spouse, and have been living separated and apart from my spouse since In witness whereof, I have signed in
Year Month Day

____________________________________________________________

______ ,
City / Country Year Month Day

____________________________________________________________

________
Signature of the spouse accompanying the principal applicant

DECLARATION BY DE FACTO SPOUSE
Declaration of the principal applicant I, the undersigned ____________________________________________________________

___________ declare that
First name and family name

Please indicate if the statements below correspond to your situation. No Yes I live conjugally with and cohabit with I live conjugally with

____________________________________________________ since
First name and family name Year Month Day

____________________________________________________________

______ since
First name and family name Year Month Day

but, being subject to persecution or penal control, we cannot live together. In witness whereof, I have signed in ____________________________________________________________

______ ,

____________________________________________________________

________
Signature of the principal applicant

City / Country

Year

Month

Day

Declaration of de facto spouse accompanying the principal applicant
I, the undersigned

____________________________________________________________

___________ declare that
First name and family name

Please indicate if the statements below correspond to your situation. Yes No I live conjugally with and cohabit with I live conjugally with

____________________________________________________ since
First name and family name Year Month Day

____________________________________________________________

______ since
First name and family name Year Month Day

but, being subject to persecution or penal control, we cannot live together. In witness whereof, I have signed in

____________________________________________________________

______ ,
City / Country Year Month Day

____________________________________________________________

________
Signature of de facto spouse accompanying the principal applicant

Ministère de l’Immigration et des Communautés culturelles

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