application for temporary resident visa made outside of canada

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APPLICATION FOR TEMPORARY RESIDENT VISA MADE OUTSIDE OF CANADA
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1. UCI/Client ID
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PERSONAL DETAILS
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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
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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
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Status (citizen/permanent resident/
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b) (If you are married or in a common-law relationship)
Provide the date on which you were married or entered
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PAGE 2 OF 4
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Applicant Name
Date of birth
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PERSONAL DETAILS (CONTINUED)
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11. Have you previously been married or in a common-law
relationship?
No
Yes
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Provide the following details for your previous Spouse/
Common-law Partner
Family name
Given name(s)
Type of relationship (common-law/married)
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PASSPORT
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1. Passport number
2. Country of issue
3. Issue date
4. Expiry date
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CONTACT INFORMATION
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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.
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Street name
City/Town
Country
Province/State
Postal code
District
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2. Residential address
Same as mailing address
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Street name
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Province/State
Postal code
District
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Number
Extension
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DETAILS OF VISIT TO CANADA
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1. a) Purpose of my visit (business/tourism/other)
b) Other
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2. Indicate how long you will stay
From (YYYY/MM/DD)
To (YYYY/MM/DD)
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3. Funds available for your stay ($CAD)
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4. Name, address and relationship of any person(s)
or institution(s) I will visit:
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(1) Name
Relationship to me
Address in Canada
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PAGE 2 OF 4
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Applicant Name
Date of birth
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EDUCATION
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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
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EMPLOYMENT
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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.
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BACKGROUND INFORMATION
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You must complete this section if you are 18 years
of age or older.
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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
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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
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c) If you answered “yes” to question 1 a) or 1 b),
please provide details and the name of the family
member (if applicable).
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b) Have you ever been refused any kind of visa to travel to
Canada?
No
Yes
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2. a) Have you ever previously applied for any Canadian
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visas (e.g. Permanent Resident, Student, Worker, Temporary
Resident (Visitor), Temporary Resident Permit)?
No
Yes
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c) Have you ever been refused admission or ordered
to leave Canada or any other country?
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d) If you answered “yes” to question 2a), 2b), or
2c) please provide details.
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PAGE 4 OF 4
4
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Applicant Name
Date of birth
BACKGROUND INFORMATION (CONTINUED)
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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
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b) If you answered “yes” to question 4a) please provide
dates of service and countries where you served
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5. Have you ever been employed by a government in
a security-related capacity?
No
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6. Have you ever held a position of authority in any
government, or judiciary or a political party?
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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
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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.
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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.
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I declare that I have answered all questions in this
application fully and truthfully.
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Signature of Applicant or Parent/Legal Guardian’s for a
person under 18 years of age
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Date: YYYY-MM-DD
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