| PLEASE SPECIFY CATEGORY FOR WHICH YOU ARE APPLYING | Self Employed |
|---|---|
| PERSONAL INFORMATION | PERSONAL INFORMATION |
| Title | Mr. |
| First Name | Mas agung |
| Middle Name | Mas agung afandi |
| Last Name | afandi |
| Place of Birth | Ngawi |
| Country of Citizenship | Indonesia |
| EDUCATION |
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| LANGUAGE PROFICIENCY | LANGUAGE PROFICIENCY PRINCIPAL APPLICANT |
| English |
|
| French |
|
| Specify Other Language | Bahasa Indonesia |
| MARITAL STATUS | Married |
| LANGUAGE PROFICIENCY SPOUSE | LANGUAGE PROFICIENCY SPOUSE |
| English |
|
| French |
|
| Specify Other Language | Bahasa Indonesia |
| SPOUSE DETAIL | SPOUSE DETAIL |
| Title | Mrs. |
| First Name | Mas agung |
| Middle Name | Mas agung afandi |
| Last Name | afandi |
| Birth Date (m/d/y) | 5/9/1988 |
| Place of Birth | Malang |
| Country of Citizenship | Indonesia |
| N.B. Additional information on your spouse (if applicable), i.e. education, work experience could be provided on extra Space below | Nursery sister |
| CHILDREN'S DETAIL (IF ANY) | CHILDREN'S DETAIL (IF ANY) |
| 1. Name | Najwa afandi |
| Date of Birth (mm/dd/yyyy) | 3/8/2009 |
| Place of Birth | Bekasi |
| 2. Name | Zahwa afandi |
| Date of Birth (mm/dd/yyyy) | 8/11/2103 |
| Place of Birth | Bekasi |
| 3. Name | Fatimah afandi |
| Date of Birth (mm/dd/yyyy) | 28/2/209 |
| Place of Birth | Malang |
| DO YOU HAVE ANY RELATIVES IN CANADA? | No |
| WHERE DO YOU INTEND TO LIVE IN CANADA? | WHERE DO YOU INTEND TO LIVE IN CANADA? |
| City/Town | Cargali |
| Province | Alberta |
| CONTACT DETAILS | CONTACT DETAILS |
| Address | Citra pesona buring raya blok c1 no. 16 kelas. Wonokoyo kec. Kedungkandang kota malang Jawa Timur |
| Contact Number | (021) 885-7320 |
| Email Address | Email hidden; Javascript is required. |
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- Address: Madison Centre Tower | 4950 Yonge Street | Suite 1000 | Toronto | Ontario | M2N 6K1
- Email Address: inquiry@cpnis.com
