Type of application:
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. If you need more space for any section, print out an additional page containing the appropriate section, complete and submit it with your application.
SEE NOTE 1
Date of Birth
(if deceased:given city/town, country and date)
will accompany you to canada?
Annulled marriageCommon-lawDivorceLegally separatedMarriage physically presentMarriage not physically presentSingleWidowed
Country of birth:
NOTE 1: If no spouse or common-law partner is listed in Section A, read and sign below.
I certify that I do not have a spouse or a common-law partner.
(Include ALL sons and daughters, including ALL adopted and step-children, regardless of age or place of residence)
SEE NOTE 2
NOTE 2: If no children are listed in Section B, read and sign below.
I certify that I do not have any natural, adopted nor step-children.
(Include ALL brothers and sisters, ALL half-brother and sister and stepbrother and sister.)
I certify that the information contained in this document is complete, accurate and factual. I also realize that once this document has been completed and signed that it
will form part of my Immigration Record and will be used to verify my family details on future applications.
The information you provide on this form is collected under the authority of the Immigration and Refugee Protection Act to determine if you may be admitted to Canada as a temporary resident. It will be stored in Personal Information Bank CIC PPU 055, Visitor Case File. It is protected and accessible under the Privacy Act and the
Access to Information Act.