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    Citizenship and Immigration Canada (CIC), or an organization at CIC' request, may want to contact you in the future to ask you about any services you received from CIC prior to the application process (such as participation in an information forum), during the application process (including the application process itself as well as orientation or accreditation services), and services received after arriving in Canada (including settlement, integration and citizenship). CIC will use this information, along with the information provided by other individuals, for research, performance measurement or evaluation purposes. CIC will not use this information to make any decisions about you personally.

    I consent to the release to Citizenship and Immigration Canada (CIC) and Canada Border Services Agency (CBSA) of all records and information for the purpose of processing my request that any government authority, including police, judicial and state authorities in all countries in which I have lived may possess about me. This information will be used to evaluate my suitability for admission to Canada or remain in Canada in pursuant to Canadian legislation.

    I declare that I have answered all questions in this application fully and truthfully.


    Personal information provided on this form is collected and will be used, disclosed, and retained by Immigration, Refugees and Citizenship Canada (IRCC) under the authority of the immigration and Refugee Protection Act (IRPA). The personal information provided will be used for the purpose of processing applications. The personal information provided may be disclosed to other federal government institutions and third parties including law enforcement bodies, provincial/territorial governments and/or foreign governments for the purpose of validating identity, eligibility and admissibility.

    The personal information collected on an application, and other information collected in support of an application, may be used for computer analytics to support processing of applications and decision making, including your application. Personal information, including from computer analytics, may also be used for purposes including research, statistics, program and policy evaluation, internal audit, compliance, risk management, strategy development and reporting.

    Where biometrics are provided in support of an application, the fingerprints collected will be stored and shared with the RCMP. The fingerprint record may also be disclosed to law enforcement agencies in Canada in accordance with subsection 13.11(1) of the Immigration and Refugee Protection Regulations. The information may also be used to establish and verify the identity of a person in order to prevent, investigate, or prosecute an offence under any law of Canada or a Province. This information may also be used to establish or verify the identity of an individual whose identity cannot reasonably be otherwise established or verified becuase of physical or mental condition. Canada may also share immigration information related to biometric records with foreign governments with whom Canada has an agreement or arrangement.

    Failure to complete the form in full may result in delay or the application not being processed. The Privacy Act gives individuals the right of access to protection, and correction of their personal information. Further details are available in Info Source. If you are not satisfied with the manner in which IRCC handles your personal information, you may exercise your right to file a complaint to the Office of the Privacy Commissioner of Canada. The collection, use, disclosure and retention of your personal information is further described in IRCC's personal information bank - IRCC PPU 068.


      Complete ALL names in English and in your native language (for example, Arabic, Cyrillic, Chinese, Chinese commercial/telegraphic code, Korean or Japanese characters). Include ALL family members even if they are not accompanying you.


      Relationship: Applicant

      Relationship: Spouse or common-law partner

      Relationship: Mother

      Relationship: Father

      I certify that I do not have a spouse or common-law partner (if you have not listed a spouse or common-law partner above))


      Include ALL sons and daughters, including ALL adopted and step-children, regardless of ageor place of residence.

      I certify that I do not have any natural, adopted nor step-children (If you have not listed any children above)


      Include ALL brothers and sisters, ALL half-brother and sister and stepbrother and sister.


        You must complete this section if you are 18 years of age or older.

        Have you ever committed, been arrested for, been charged with or convicted of any criminal offence in any country or territory?

        Did you serve in military, militia, or civil defence unit or serve in a security organization or police force (including non obligatory national service, reserve or volunteer units)?


          Indicate how long you plan to stay

          Name, address, and relationship of any person(s) or institution(s) I will visit:


          Have you had any post secondary education (including university, college or apprenticeship training)? If yes, give full details of your highest level of post secondary education.


          Give details of your employment for the past 10 years, including if you have held any government positions (such as civil servant, judge, police officer, mayor, Member of Parliament, hospital, administrator, employee of a security organization). Do no leave gaps. If retired, not working or studying, please indicate. If you are retired, please provide the 10 years before your retirement.


            If submitting your application by mail: all correspondence will go to this address unless you indicate your e-mail address below; Indicating an e-mail address will authorize all correspondence, including file and personal information, to be sent to the e-mail address you specify. If you wish to authorize the release of information from your application to a representative, indicate their e-mail and mailing address(es) in this section and on the IMM5476 form.

            Current mailing address

            Residential Address: Different from mailing address?

            Telephone no.

            Alternative Telephone no.

            Fax no.




              Do you have a national identity document?

              US PR CARD

              Are you a lawful Permanent Resident of the United States with a valid alien registration card (green card)?

                PERSONAL DETAILS

                Have you ever used any other name (e.g. Nickname, maiden name, elias, etc)?

                Current country or territory of residence

                Previous countries or territory of residence: During the past five years have you lived in any country or territory other than your country of citizenship or your current country or territory of residence (indicated above) for more than six months?

                Country or Territory Where Applying: Different from current country or territory of residence?

                Provide Name of Your Current Spouse or Common-Law Partner

                Have you previously been married or in a common-law relationship (If yes, provide the details below for your previous Spouse/Common-law Partner)?