IMM1295 OUTSIDE CANADA



PERSONAL DETAILS



NoYes





NoYes

NoYes



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NoYes


Language

NoYes

Passport

YesNo
YesNo

NATIONAL IDENTITY DOCUMENT

YesNo
1
2
3
4

US PR CARD

YesNo
2
3

CONTACT INFORMATION

- 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.

NoYes
Canada/US
Others




Canada/US
Others


Canada/US
Others



DETAILS OF INTENDED WORK IN CANADA


DETAILS OF INTENDED WORK IN CANADA (CONTINUED)

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EDUCATION

NoYes


EMPLOYMENT

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.)





BACKGROUND INFORMATION

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

1

NoYes
NoYes

BACKGROUND INFORMATION (CONTINUED)

2

NoYes
NoYes
NoYes
3

NoYes

4

NoYes

5

NoYes
6

NoYes

If you answered “yes” to any of questions 3 to 6 above, or upon request of a visa officer, you MAY BE REQUIRED to fill out IMM 5257 Schedule 1.

SIGNATURE

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.

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 to remain in Canada pursuant to Canadian legislation.

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

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IMPORTANT NOTE:

This application must be signed and dated before it is submitted by mail.

Do not forget to include photos, fees (if applicable) and any other documents required. Review the application guide for more information and verify that you have completed and provided all of the required documents as per the document checklist.

DISCLOSURE

The information you provide to CIC is collected under the authority of IRPA to determine if you may be admitted to Canada as a worker. The information may be shared with other organizations such as CBSA, DFAIT, RCMP, CSIS and foreign governments in accordance with subsection 8(2) of the Privacy Act. Information may also be disclosed to foreign governments, law enforcement bodies and detaining authorities with respect to the administration and enforcement of immigration legislation where such sharing of information may not put the individual and or his/her family at risk. Information may also be systematically validated by other Canadian government institutions under the terms of an agreement or arrangement for the purposes of validating status and identity to administer their programs

If you are required to provide biometric information to accompany your application, the fingerprints collected will be stored and shared with the RCMP and the fingerprint record may also be disclosed to law enforcement agencies in Canada in accordance with subsection 13.11 of the Immigration and Refugee Protection Regulations. This information may be used in relation to an offence under any law of Canada or a province for the purposes of establishing or verifying the identity of an individual, or to establish or verify the identity of an individual whose identity cannot reasonably be otherwise established or verified because of physical or mental condition.

The information you provide to CIC will be stored in the Personal Information Bank (CIC PPU (039 and 054). Ifare required to provide biometric information, your shared with the RCMP will be stored in the PIB CMP PPU 030. Individuals have a right to protection of and access to their personal information stored in each corresponding PIB in accordance with the Privacy Act and the Access to Information Act. Details on these matters are available at the Infosource website (http://infosource.gc.ca) and through the CIC Call Centre. Infosource is also available at public libraries across Canada.