JAJ Immigration Consultancy
Your family name (as shown on your passport or travel document)*
Your given names ((as shown on your passport or travel document)
Please leave this field empty.
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.
Do you consent to be contacted by CIC, or an organization at CIC's request, in the future? (Y/N)*NoYes
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.
Signature of Applicant or Parent/Legal Guardian's or a person under 18 years of age*
Date*
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.
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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.
SECTION A
Relationship: Applicant
Name
Marital Status*Annulled MariageCommon-LawDivorcedLegally SeparatedMarriedSingleUnknownWidowed
Date of Birth
Country of Birth
Present Occupation
Present Address (if deceased, give city/town, country and date)
Relationship: Spouse or common-law partner
Will accompany you to Canada?YesNo
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))
Signature Clear
Date
SECTION B - CHILDREN
Include ALL sons and daughters, including ALL adopted and step-children, regardless of ageor place of residence.
Relationship
I certify that I do not have any natural, adopted nor step-children (If you have not listed any children above)
SECTION C - BROTHERS AND SISTERS
Include ALL brothers and sisters, ALL half-brother and sister and stepbrother and sister.
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You must complete this section if you are 18 years of age or older.
Within the past two years, have you or a family member ever had tuberculosis of the lungs or been in close contact with a person with tuberculosis?NoYes
Do you have any physical or mental disorder that would require social and/or health services, other than medication, during a stay in Canada?NoYes
If you answered yes to any of the last two questions, please provide details and the name of the family member (if applicable).
Have you ever remained beyond the validity of your status, attended school without authorization or worked without authorization in Canada?NoYes
Have you ever been refused a visa or permit, denied entry or ordered to leave Canada or any other country or territory?NoYes
Have you previously applied to enter or remain in Canada?NoYes
If you answered yes to the any of the last three questions, please provide details.
Have you ever committed, been arrested for, been charged with or convicted of any criminal offence in any country or territory?
If yes, pease provide details
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)?
If you answered yes, please provide dates of service and countries or territories where you served.
Are you, or have you ever been a member or associated with any political party, or other group or organization which has engaged in or advocated violence as a means to achieving political or religious objective, or which has been associated with criminal activity at any time?NoYes
Have you ever witnessed or participated in the ill treatment of prisoners or civilians, looting or desecration of religious buildings?NoYes
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Purpose of my visit*BusinessTourismShort-Term StudiesReturning WorkerSuper Visa: For Parents or GrandparentsOtherFamily VisitVisit
Other
Indicate how long you plan to stay
From*
To*
Funds available for my stay (CAD)*
Name, address, and relationship of any person(s) or institution(s) I will visit:
Name*
Relationship to me*
Address in Canada*
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.
From
To
Field of study
City/Town
School/Facility Name
Country or Territory
Province/State
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.
Activity/Occupation
Company/Employer/Facility Name
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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
P.O. box
Apt/Unit
Street no.
Street name*
City/Town*
Country or Territory*
Postal Code
District
Residential Address: Different from mailing address?
Telephone no.
Type*ResidenceCellularBusiness
Country Code*
No.*
Ext.
Alternative Telephone no.
TypeResidenceCellularBusiness
Country Code
No.
Fax no.
E-mail address
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What is your native language/mother tongue?*
Are you able to communicate in English and/or French?*EnglishFrenchBothNeither
In which language, of the two, are you most at ease?
Have You Taken A Test From A Designated Testing Agency to Assess Your Proficiency in English or French?NoYes
Passport Number*
Country or Territory of Issue*
Issue Date*
Expiry Date*
For this trip, will you use a passport issued by the Ministry of Foreign Affairs in Taiwan that includes your personal identification number?*NoYes
For this trip, will you use a National Israeli passport?*NoYes
Do you have a national identity document?
Document number
Country or territory of issue*
Issue date
Expiry date
Are you a lawful Permanent Resident of the United States with a valid alien registration card (green card)?
Document number*
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Have you ever used any other name (e.g. Nickname, maiden name, elias, etc)?
Family name
Given name(s)
Sex*M MaleF FemaleU UnknownX Another gender
Date of birth*
Citizenship*
City/Town of birth*
Country or Territory of birth*
Current country or territory of residence
Status*CitizenPermanent ResidentVisitorWorkerStudentOtherProtected PersonRefuge ClaimantForeign National
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?
StatusCitizenPermanent ResidentVisitorWorkerStudentOtherProtected PersonRefuge ClaimantForeign National
Country or Territory Where Applying: Different from current country or territory of residence?
Your Current Marital Status*Annulled MariageCommon-LawDivorcedLegally SeparatedMarriedSingleUnknownWidowed
If you are married or in a common-law relationship, provide the date on which you were married or entered into the common-law relationship
Provide Name of Your Current Spouse or Common-Law Partner
Family Name
Given Name(s)
Have you previously been married or in a common-law relationship (If yes, provide the details below for your previous Spouse/Common-law Partner)?
Type of RelationshipCommon-LawMarried
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UCI
I want service in*EnglishFrench
Visa requested*Visitor VisaTransit
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