PAGE 1 OF 4 1 4 APPLICATION FOR TEMPORARY RESIDENT VISA MADE OUTSIDE OF CANADA ! ! " !#! $%$ ! &! , ($& $! ( !&! # 1. UCI/Client ID ( 2. I want service in + 3. Visa requested 9 ," -. / / !( 0 ( " !, &* ! "!) , -" 0 ) –/ , !, 3) !–/ , 3) PERSONAL DETAILS + *! & *! 1. Full name Family name (as shown on your passport or travel document) Given name(s) (as shown on your passport or travel document) 2. Have you ever used any other name? Yes No Nick names/Alias < A ! !( !, - / " - ), - / " - Family name Given name(s) E 0 - , " 3 / H J H -0 " 3 / ! " -. " / , A ! !( ) 3. Sex < 4. Date of birth (YYYY/MM/DD) H 5. Place of birth City/town County W " . X / " Y (/ , ! 6. Citizenship Y " / (/ , 7. Current country of residence Country Status (citizen/permanent resident/ visitor/worker/student/other) Other From To Y Y Y 8. Previous countries of residence: During the past five years have you lived in any country other than your country of citizenship or your country of residence (indicated above) for more than six months No Yes Country Status (citizen/permanent resident/ visitor/worker/student/other) Other From To < -N " . / E E ^ 0 " ! , ^ " "! J H Y (/ , Y -" (0 . . / ]N / H -0 Y < 9. Country where applying: Same as current country of residence No Yes Country Y ,0 E 9 . ,M " J H Y (/ , . ! (0 0 . / "! / " . / (/ , -" (0 . . / ]N / H -0 Y < -0 ? ( ., / M3! !, / N ) 3) " ) " " ) ! / " !N " " ) / " ! ^ , -/ . / !: d - , " . / ! (- / 0 // ^ " M -M ,-/ ! 3 " / ^ ) -0 ) , /. / " " ) " ! ^ !/ " ! " 0 " ) // , -/ ^ / -: . / ! -M ,-/ -0 ) Status (citizen/permanent resident/ visitor/worker/student/other) Other From To Y -" (0 . . / ]N / H -0 Y < 10. ) Your current marital status (Annulled marriage/ common-law/divorced/legally separated/married/single/ widowed) E ^ " ( 0 / / . / " ! ^ // , -/ ^ -0 ) . / / " !N /0 . " , . / /. )// / (/ / )) -M ,-/ , 3 -. ( b) (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 >> Date (g" E . ( -. ) " " h . - /" !/, " / " 0 . / ! >> H ") Provide the name of your current spouse/common-law partner Family name Given name(s) h . 0 . A !( ] " ! ) 0 "- / ( - ! E ^ 0 "-0 ( ) / -. ( )/ ) /0 . M " , ) -0 ( )/ PAGE 2 OF 4 2 4 Applicant Name Date of birth ! H !/ . ! ! PERSONAL DETAILS (CONTINUED) + *! & *! (( $&$ /! !) 11. Have you previously been married or in a common-law relationship? No Yes Y " ! J H Provide the following details for your previous Spouse/ Common-law Partner Family name Given name(s) Type of relationship (common-law/married) From To h . " "- -0 ( ) A ! !( ) 9 ^ Y < E . -]N 0 . /, " E ^ ( 0 ) ( 0 ) ) "- -0 ( ): " (0 . 0 . " , /, , ? -N ( 0 ) ) PASSPORT ( ($ 1. Passport number 2. Country of issue 3. Issue date 4. Expiry date J " Y ,/ /^ ! H / M H " / " (/ , " " ) CONTACT INFORMATION )$ ) 0$ # 1. Current mailing address - All correspondence will be sent 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 email address. you specify - If you wish to authorize the release of information from your application to a representative, indicate their address below and on the IMM5476 form. H " /-]N M / - g" E - . E ^k /"! " ! ,-h / k 0 " 3 /"] " E ^ !/ M E k "-. - g" E . 3 E ^ -E ^ - . 0 ( ) "/ - P.O.Box Apt/Unit m/! n/ " " " 3"! k " M ], / M " , ^ " / / / M], IMM5476 . , M / ^ " ] - Street No. Street name City/Town Country Province/State Postal code District J h X / " Y (/ , < / !/^ < M / o -0 2. Residential address Same as mailing address No Yes Apt/Unit Street No. Street name City/Town Country Province/State Postal code District m " M " 0 9 . M / J H n/ J h X / " Y (/ , " < / !/^ (/ , < M / " o -0 3. Telephone number Canada/US Other Type (residence, cellular, business) Country code Number Extension J En /Yqm E -0 " 9 ( ^ / n " J H , / M , 3 / , M ,/ , " " ) 4. Alternate Telephone No. Canada/US Other Type (residence/cellular/business) Country code Number Extension m 3 / En /Yqm E -0 " 9 ( ^ / n " J H , / M , 3 / , M ,/ , " " ) 5. Fax No. Canada/US Other Country code Number Extension A " En /Yqm E -0 " n " J H , / M 6. E-mail address m DETAILS OF VISIT TO CANADA 0$ # $ ($! &)! ) " (/ , " "k " ) " . / " " ) ! " ) " " ) M &" 1. a) Purpose of my visit (business/tourism/other) b) Other r 3 H -0 ! ( 2. Indicate how long you will stay From (YYYY/MM/DD) To (YYYY/MM/DD) h . " Y (0 / "! / 3) < (0 / "! / 3) 3. Funds available for your stay ($CAD) Y 4. Name, address and relationship of any person(s) or institution(s) I will visit: A (1) Name Relationship to me Address in Canada A n m " / - (/ !/ ! ( / t( ) ! " , !/ t "/n / !/ - ) ]"3 !( / ) "!/ ^ / 0 -0 !, / , , / " t " ) ! t) 0 " " 3, , E t ! "! (2) Name Relationship to me Address in Canada A n m !/ t "/n !( / ) "!/ ^ PAGE 2 OF 4 3 4 Applicant Name Date of birth ! H !/ . ! ! EDUCATION $2 $ ! Have you had any post secondary education (including university, college and apprenticeship training)? No Yes If you have answered yes, please give full details of your highest level of post secondary education. (1) From (YYYY/MM) To (YYYY/MM) Field of study School/Faculty name City/town Country Province/State o,-M "3 E 0 - , M (/ M " /- / " , . "" 3 / t - ) J H g" E / , " /3 / "^ " , -M ^ . C (0 / "! ) < (0 / "! ) Y 3 " 3 hM , / X / " Y (/ , < / !/^ / " ^ , -] E ] " " - 3 " " ) EMPLOYMENT 2$ Give full details of your employment for the past 10 years. If retired, not working or studying, please indicate. If you are retired, provide the 10 years before your retirement. < " /3 -] ] 10 . g" E " , , g" E " , " /3 / t " ]. E ^ (1) From (YYYY/MM) To (YYYY/MM) Activity/Occupation Company/Employer/Facility name City/town Country Province/State C (0 / "! ) < (0 / "! ) H . " 3/ ! 3 " o 0 !/ , 3/ X / " Y (/ , " " ) < / !/^ ! (2) From (YYYY/MM) To (YYYY/MM) Activity/Occupation Company/Employer/Facility name City/town Country Province/State C (0 / "! ) < (0 / "! ) H . " 3/ ! 3 " o 0 !/ , 3/ X / " Y (/ , " " ) < / !/^ ! (3) From (YYYY/MM) To (YYYY/MM) Activity/Occupation Company/Employer/Facility name City/town Country Province/State C (0 / "! ) < (0 / "! ) H . " 3/ ! 3 " o 0 !/ , 3/ X / " Y (/ , " " ) < / !/^ ! , " -M "3, - . . ] 10 , BACKGROUND INFORMATION 2 $% 0 +! ) ! & *! You must complete this section if you are 18 years of age or older. E . , 3^ . 1. a) 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? No Yes d M / J H b) Do you have any physical or mental disorder that would require social and/or health services, other than medication, during a stay in Canada? No Yes Y E - , - " / , / , , N ! " 3 ( ! ! " / n ? J H c) If you answered “yes” to question 1 a) or 1 b), please provide details and the name of the family member (if applicable). g" E / . - " , . - . " /" J H b) Have you ever been refused any kind of visa to travel to Canada? No Yes o , " / 0 , -, " 3 ! 2. a) Have you ever previously applied for any Canadian < visas (e.g. Permanent Resident, Student, Worker, Temporary Resident (Visitor), Temporary Resident Permit)? No Yes 3k « » " /3 E E t ]N 0 ,, t -, . , / 3 " -" -0 " /) / / ! , / t" / "1 ) 1 ,), , , -] ]/ ! M " 3 ( " E 0 - , !/ ! , / /n -( ./ ( 0 !), ^ ! ^ ! -M ,-, / / 0 ^ !/ 0 )? E E ^ t "3 ? M " / - / 18 0 - , / !/ ], ). -M " ! 0 , -, (0 " / !), - , / /n -? J H c) Have you ever been refused admission or ordered to leave Canada or any other country? No Yes o / J H d) If you answered “yes” to question 2a), 2b), or 2c) please provide details. g" E / . - " , E E , 0 - / /z - 3n « » " /3 / , - " / ],-] -0-] " " 2 ), 2b) 2c), , -] -? ]. PAGE 4 OF 4 4 4 Applicant Name Date of birth BACKGROUND INFORMATION (CONTINUED) 2 $% 0 +! ) ! & *! (( $&$ /! 3. Have you ever committed, been arrested for or been charged with any criminal offence in any country? No Yes 4. a) Have you ever been in a military, militia or civil defense unit? No Yes ! H !/ . ! ! !) Y / ^ / 0 " J H < E "3 / t " J H 0 " - E M " - 0 - , , , " "-. ? ,- 3 , " -.,- / / 0 . " - , " , , ? b) If you answered “yes” to question 4a) please provide dates of service and countries where you served g" 5. Have you ever been employed by a government in a security-related capacity? No Yes { , . J H 6. Have you ever held a position of authority in any government, or judiciary or a political party? d E ], 0 - / ! / M " J H No Yes 7. Have you ever in periods of either peace or war, been involved in the commission of a war crime or crime against humanity, such as: willful killing, torture, attacks upon, enslavement, starvation or other inhumane acts committed against civilians or prisoners of war, deportation of civilians? No Yes E / t " -., " E " , "/! « » / " 4 ), t, 0 E t 0 - , / / " , " M 0 / " /3 " -.,-. 3" / , , - / !N-] 3" / , "- , t ? ] 0 " . 0 / " " 3 t hM " / / E ,/ / ! / / " / ,/" / ^ / t " " /M / M " , t : -, " / , , , , N " . /0 t -" / !t -0 t . " t " / ^ t /0 . " 0 " ! / t, 0 . " 0 " !? J H t , " / !t, If you answered “yes” to any of questions 3) through 7) above, or upon request of a visa officer, you MAY BE REQUIRED to fill our IMM5257 Schedule 1. !HIJ K LMNOMJIJ «QR» TR IUVLW JX NLYZLHLN H 3) YL 7) _`RXRTTKa NKbO, JIJ YL XRYZLH_ NJXLNLcL LdJeOZR, Rf, NLXfLkTL, ($ !2"! XRYLITJMl (ZJILkOTJO 1 IMM5257 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 to remain in Canada pursuant to Canadian legislation. + " 0 " (" ) / M- W " " /- X . " / 0 n (CIC) n " -< 0 M m0 " /- (CBSA) /" t t 0- / 3 ], 0 0 "- " / / " , / ]M ! ]/ ], "- , 0 0 0 "- " / 0 - / ! / /" t " t, / t ! . / ( )," 3] "" ! 0 !/ !. } ! ," 3 / ! 0 ,M , 3, " 3 ! / M ] , / ! /z /n t . !/n ,/" / " / " " 3" / . I declare that I have answered all questions in this application fully and truthfully. + Signature of Applicant or Parent/Legal Guardian’s for a person under 18 years of age < Date: YYYY-MM-DD H !/ !], M " 3] "3 ! :0 !/ // / / ( ) / / . /" / ! !/ " "! / " ^ 18 3 0 . -