Guide 1016 – Application guide for Health-care Workers Permanent Residence Pathway (COVID-19 pandemic)

Table of Contents

• Overview
• Before you apply
• Step 1. Gather documents
• Step 2. Complete the Application
• Step 3. Pay the Fees
• Step 4. Mail the Application
• What Happens Next
• Need help?
• Appendix A: Police Certificates

Other relevant definitions can be found in the applicable public policies. For further information see the:

• Temporary Public Policy to facilitate the granting of Permanent residence for certain refugee claimants working in the health care sector during the COVID-19 pandemic
• Temporary Public Policy to facilitate the granting of Permanent residence for certain foreign nationals selected by Quebec working in the health care sector during the COVID-19 pandemic

Before you apply

Who may use this application?

In recognition of their exceptional service, Immigration, Refugees and Citizenship Canada (IRCC) put in place a Temporary Public Policy to facilitate the granting of permanent residence for certain refugee claimants working in Canada’s health-care sector, providing direct patient care, during the COVID-19 pandemic.

Recognizing the unique selection authority of Quebec, established under the Canada-Quebec Accord, a separate public policy for those intending to reside in Quebec has also been developed.

Pending and failed refugee claimants intending to reside in a province or territory other than Quebec:

To qualify for Permanent Residence, you must meet the following criteria.

• you are a pending refugee claimant or a failed refugee claimant who made a refugee claim in Canada prior to March 13, 2020 and have continued to reside in Canada.

  Note: A pending refugee claimant is a person who made a refugee claim in Canada prior to March 13, 2020, and whose claim had not been decided by the Refugee Protection Division (RPD) or the Refugee Appeal Division (RAD) of the Immigration and Refugee Board (IRB) when their application for permanent residence under the public policy is made, up until a final decision under the public policy is rendered.

  A failed refugee claimant is a person who made a refugee claim in Canada prior to March 13, 2020, and who received a final negative decision by the IRB on their claim. This includes claimants who have commenced an application for leave and judicial review of the negative IRB decision in Federal Court, or an appeal in relation to the underlying IRB decision at the Federal Court of Appeal.

• you have been authorized to work in Canada by virtue of a work permit or work permit exemption under section 186 of the Immigration and Refugee Protection Regulations (the Regulations), unless you lost your authorization to work as a result of a removal order against you becoming enforceable due to a final negative decision on your refugee claim, in which case work you performed subsequent to the loss of that authorization need not be authorized.
• you worked in Canada in one or more designated occupations (see Annex A) providing direct patient care in a hospital, public or private long-term care home or assisted living facility, or for an organization/agency providing home or residential health-care services to seniors and persons with disabilities in private homes:
  • for a minimum of 120 hours (equivalent to 4 weeks full-time) between March 13, 2020 and August 14, 2020; and,
  • for a minimum of 6 months full-time (30 hours per week) or 750 hours (if working part-time) total experience (obtained no later than August 31, 2021), and

  • for greater certainty, periods of work in a designated occupation must be paid unless the applicant was doing an internship that is considered an essential part of a post-secondary study program or vocational training program in one of the designated occupations or internship performed as part of a professional order requirement in one of the designated occupations.

    Note: Applicants who complete their work experience prior to August 31, 2021, are expected to submit evidence within 60 days of completion.

    Periods of paid or unpaid sick leave may be counted when assessing the 120 hours or the 6-month experience requirement if the applicant contracted COVID-19. Periods of paid or unpaid leave due to illness/disability, maternity/parental leave, quarantine or isolation requirements due to COVID-19, caring for family who contracted COVID-19 or lack of child care due to COVID-19 may be counted when assessing the 6 month experience requirement. Evidence to support the leave must be submitted.

• you and your family members are not inadmissible other than for any of the following reasons:
  • having failed to comply with conditions related to your temporary stay including:
    • having overstayed:
      • a visa,
      • a visitor record,
      • a work permit,
      • a student permit;
  • or having worked or studied without being authorized to do so under the Act (as long as it was solely as a result of losing the work authorization when a removal order against you became enforceable);
  • having entered Canada without the required visa or other document required under the Regulations

  • having entered Canada without a valid passport or travel document.

    Note: For the purpose of the granting of the permanent residence pursuant to this public policy, you and your family members are required by subparagraph 72(1)(e)(ii) of the Regulations to provide the Department of Immigration, Refugees and Citizenship Canada any of the documents enumerated under subsection 50(1) of the Regulations. If you and your family members in Canada are unable to obtain any of the documents, enumerated under subsection 50(1) of the Regulations (e.g, valid passport or travel document), as required by subparagraph 72(1)(e)(ii) of the Regulations, an exemption from this requirement can be granted if you can provide any of the documents described in subsection 178(1) of the Regulations if such alternative document complies with the requirement of subsection 178(2) of the Regulations.

    Note: As a final condition, before we can grant you permanent residence, we will send you a separate letter inviting you and the family members included in your application to either:

    • withdraw your pending refugee claim or refugee appeal, before the Refugee Protection Division (RPD) or the Refugee Appeal Division (RAD) of the Immigration, Refugee Board (IRB), or
    • discontinue your application at the Federal Court (FC) or your appeal at the Federal Court of Appeal (FCA) in relation to an underlying negative IRB decision on your refugee claim.

    

    Important notes:

    • If you withdraw your claim before the IRB before receiving instructions to do so, your application for permanent residence under the public policy will be refused. Once you withdraw a claim before the IRB, future refugee claims will be ineligible as per 101(1)(c) of the IRPA.
    • Wait for the instruction letter before abandoning your application for leave to the FC or your appeal at the FCA.

    Should the individual decide not to withdraw or discontinue, as mentioned above, those processes will proceed and their application for permanent residence under the public policies will be refused.

The work experience must be in a designated occupation providing direct patient care in health-care institutions, more specifically:

• a hospital
• a public or private long term care home
• a public or private assisted living facility
• an organization/agency providing home or residential health-care services to seniors and persons with disabilities in private homes.

Designated occupations

Designated occupations for provinces and territories other than Quebec can be found in Annex A of the Public Policy:

Designated occupations - National Occupational Classification (NOC) codes :

• 3011 – Nursing co-ordinators and supervisors
• 3012 – Registered nurses and registered psychiatric nurses
• 3124 – Allied primary health practitioners
• 3233 – Licensed practical nurses
• 3413 – Nurse aides, orderlies and patient service associates

Other designated occupations:

• 4412 – Home support workers, housekeepers and related occupations only

To be eligible under the NOC code 4412 for this public policy:

• you must be engaged in providing basic personal care services and offering physical assistance directly to patients by primarily performing some or all of these duties:
  • Provide care and companionship for individuals and families during periods of incapacitation, convalescence or family disruption
  • Administer bedside and personal care to clients such as aid in ambulation, bathing, personal hygiene, and dressing and undressing
  • May perform routine health-related duties such as changing non-sterile dressings, assisting in the administration of medications and collecting specimens under the general direction of a home care agency supervisor or nurse
• you may also perform duties listed below, in addition to the above mentioned duties:
  • Plan and prepare meals and special diets, and feed or assist in feeding clients
  • Perform routine housekeeping duties such as laundry, washing dishes and making beds

• Note: You must demonstrate that the principal care services provided are for the patient and not their family. In addition, the onus is on you to demonstrate that you predominantly provided personal care and support services as per the main duties described in the NOC occupational description, with any performance of routine housekeeping duties such as laundry, washing dishes, etc., being incidental to your primary role providing direct in-home care.

  Note: Self-employed caregivers or those who are employed by private households (directly employed by the person receiving care, or by the family/guardians of the person receiving care) are excluded from this public policy.

You must demonstrate that you are primarily engaged in activities represented in the eligible occupation and indicate your National Occupational Classification (NOC) code(s) in Schedule 1 - Health-care Workers Permanent Residence Pathway (COVID-19 pandemic) [IMM 1018] (opens in a new tab)

This means that the main duties of your employment activities must align with the descriptions found in the NOC list for the eligible occupations.

For the periods of work experience claimed in the application, you must demonstrate both of the following:

• the actions identified in the initial lead statement of the NOC description, and

• a number of the main duties listed in the NOC description.

  Note: Periods of work in a designated occupation must be paid unless you were doing an internship that is considered an essential part of a post‑secondary study program or vocational training program in one of the designated occupations or an internship performed as part of a professional order requirement in one of the designated occupations.

IRCC will review the main duties and principal business activities indicated in Schedule 1 and supporting documents to make sure that the work experience meets the occupational classification.

Pending or failed refugee claimants intending to reside in Quebec:

To qualify for Permanent Residence, you must meet the following criteria:

• you are a pending refugee claimant or a failed refugee claimant who made a refugee claim in Canada prior to March 13, 2020 and have continued to reside in Canada;

  Note: A pending refugee claimant is a person who made a refugee claim in Canada prior to March 13, 2020, and whose claim had not been decided by the Refugee Protection Division (RPD) or the Refugee Appeal Division (RAD) of the Immigration and Refugee Board (IRB) when their application for permanent residence under the public policy is made, up until a final decision under the public policy is rendered.

  A failed refugee claimant is a person who made a refugee claim in Canada prior to March 13, 2020, and who received a final negative decision by the IRB on their claim. This includes claimants who have commenced an application for leave and judicial review of the negative IRB decision in Federal Court, or an appeal in relation to the underlying IRB decision at the Federal Court of Appeal.

• you have been authorized to work in Canada by virtue of a work permit or work permit exemption under section 186 of the Immigration and Refugee Protection Regulations (the Regulations), unless you lost your authorization to work as a result of a removal order against you becoming enforceable due to a final negative decision on your refugee claim, in which case work you performed subsequent to the loss of that authorization need not be authorized.
• you have been issued a Certificat de sélection du Québec (CSQ) under the Special program for asylum seekers during the COVID-19 period.
• you and your family members are not inadmissible other than for any of the following reasons:
  • having failed to comply with conditions related to your temporary stay including:
    • having overstayed:
      • a visa,
      • a visitor record,
      • a work permit,
      • a student permit;
  • or having worked or studied without being authorized to do so under the Act (as long as it was solely as a result of losing the work authorization when a removal order against you became enforceable);
  • having entered Canada without the required visa or other document required under the Regulations

  • having entered Canada without a valid passport or travel document.

    Note: For the purpose of the granting of the permanent residence pursuant to this public policy, you and your family members are required by subparagraph 72(1)(e)(ii) of the Regulations to provide the Department of Immigration, Refugees and Citizenship Canada any of the documents enumerated under subsection 50(1) of the Regulations. If you and your family members in Canada are unable to obtain any of the documents, enumerated under subsection 50(1) of the Regulations (e.g, valid passport or travel document), as required by subparagraph 72(1)(e)(ii) of the Regulations, an exemption from this requirement can be granted if you can provide any of the documents described in subsection 178(1) of the Regulations if such alternative document complies with the requirement of subsection 178(2) of the Regulations.

    Note: As a final condition, before we can grant you permanent residence, we will send you a separate letter inviting you and the family members included in your application to either:

    • withdraw your pending refugee claim or refugee appeal, before the Refugee Protection Division (RPD) or the Refugee Appeal Division (RAD) of the Immigration, Refugee Board (IRB), or
    • discontinue your application at the Federal Court (FC) or your appeal at the Federal Court of Appeal (FCA) in relation to an underlying negative IRB decision on your refugee claim.

    

    Important notes:

    • If you withdraw your claim before the IRB before receiving instructions to do so, your application for permanent residence under the public policy will be refused. Once you withdraw a claim before the IRB, future refugee claims will be ineligible as per 101(1)(c) of the IRPA.
    • Wait for the instruction letter before abandoning your application for leave to the FC or your appeal at the FCA.

    Should the individual decide not to withdraw or discontinue, as mentioned above, those processes will proceed and their application for permanent residence under the public policies will be refused.

Spouses or common-law partners of deceased health-care workers:

To qualify for Permanent Residence, you must meet the following criteria:

• you are the spouse or common-law partner of a foreign national who contracted COVID-19 and passed away prior to applying for permanent residence under this public policy or after applying but before being granted permanent residence who would have met the following conditions:
  • having been a pending or failed refugee claimant prior to March 13, 2020, who continued to reside in Canada;
  • were authorized to work in Canada by virtue of a work permit or work permit exemption under section 186 of the Immigration and Refugee Protection Regulations (the Regulations), unless the individual lost their authorization to work as a result of a removal order against them becoming enforceable due to a final negative decision on their refugee claim, in which case work performed subsequent to the loss of that authorization need not be authorized.
  • and having worked in Canada in a designated occupation at any time between March 13, 2020 and August 14, 2020
• you resided in Canada prior to August 14, 2020 and have a Certificat de sélection du Québec (CSQ) under the Special program for asylum seekers during the COVID-19 period, if intending to reside in Quebec; and
• you and your family members are not inadmissible other than for any of the following reasons:
  • having failed to comply with conditions related to your temporary stay including
    • having overstayed:
      • a visa,
      • visitor record,
      • work permit,
      • student permit;
  • or having worked or studied without being authorized to do so under the Act (as long as it was solely as a result of losing the work authorization when a removal order against you became enforceable);
  • having entered Canada without the required visa or other document required under the Regulations;

  • having entered Canada without a valid passport or travel document.

    Note: For the purpose of the granting of the permanent residence pursuant to this public policy, you and your family members are required by subparagraph 72(1)(e)(ii) of the Regulations to provide the Department of Immigration, Refugees and Citizenship Canada any of the documents enumerated under subsection 50(1) of the Regulations. If you and your family members in Canada are unable to obtain any of the documents, enumerated under subsection of the Regulations (e.g, valid passport or travel document), as required by subparagraph 72(1)(e)(ii) of the Regulations, an exemption from this requirement can be granted if you can provide any of the documents described in subsection 178(1) of the Regulations if such alternative document complies with the requirement of subsection 178(2) of the Regulations.

    Note: As a final condition, before we can grant you permanent residence, we will send you a separate letter inviting you and the family members included in your application to either:

    • withdraw your pending refugee claim or refugee appeal, before the Refugee Protection Division (RPD) or the Refugee Appeal Division (RAD) of the Immigration, Refugee Board (IRB), or
    • discontinue your application at the Federal Court (FC) or your appeal at the Federal Court of Appeal (FCA) in relation to an underlying negative IRB decision on your refugee claim.

    

    Important notes:

    • If you withdraw your claim before the IRB before receiving instructions to do so, your application for permanent residence under the public policy will be refused. Once you withdraw a claim before the IRB, future refugee claims will be ineligible as per 101(1)(c) of the IRPA.
    • Wait for the instruction letter before abandoning your application for leave to the FC or your appeal at the FCA.

    Should the individual decide not to withdraw or discontinue, as mentioned above, those processes will proceed and their application for permanent residence under the public policies will be refused.

Who may not use this application?

You may not apply if:

• you are a Canadian citizen or
• you are a permanent resident
• you were determined to be ineligible to be referred to the Immigration and Refugee Board;
• your refugee claim was determined to be withdrawn or abandoned;
• your claim was determined to be manifestly unfounded or with no credible basis;
• you were excluded under Article 1F of the Refugee Convention; or
• your refugee status was determined ceased or vacated;
• you and your family members are inadmissible for reasons other than those indicated in one of the public policies

Pending refugee claimant

A pending refugee claimant is a person who made a refugee claim in Canada prior to March 13, 2020, and whose claim had not been decided by the Refugee Protection Division (RPD) or the Refugee Appeal Division (RAD) of the Immigration and Refugee Board (IRB) when their application for permanent residence under the public policy is made, up until a final decision under the public policy is rendered.

IRCC will inform the Immigration Refugee Board that you have applied for Permanent Residence under one of the public policies once your application has undergone a preliminary review. Pending claimants will have their claim put on hold by the IRB until a final decision on their application for permanent residence is rendered.

IRCC will provide the IRB with the outcome of the application for those who had their claims or appeals put on hold under these public policies.

• If you are unsuccessful under one of the public policies, the IRB will resume processing your pending claim or appeal.
• If you are successful under one of the public policies, you will be invited to withdraw your refugee claim before the RPD or refugee appeal before the RAD and discontinue your application at the Federal Court or your appeal at the Federal Court of appeal in relation to an underlying negative IRB decision.
• Should you decide not to withdraw or discontinue, as mentioned above, those processes will proceed and your application for permanent residence under the public policies will be refused.

Important notes:

• If you withdraw your claim before the IRB before receiving instructions to do so, your application for permanent residence under the public policy will be refused. Once you withdraw a claim before the IRB, future refugee claims will be ineligible as per 101(1)(c) of the IRPA.
• Wait for the instruction letter before abandoning your application for leave to the FC or your appeal at the FCA.

Failed refugee claimant

A failed refugee claimant is a person who made a refugee claim in Canada prior to March 13, 2020, and who received a final negative decision by the IRB on their claim. This includes claimants who have commenced an application for leave and judicial review of the negative IRB decision in Federal Court, or an appeal in relation to the underlying IRB decision at the Federal Court of Appeal.

Stay of removal

Upon receipt of your application, if IRCC determines that you meet the preliminary eligibility criteria, they will notify the Canada Border Services Agency and your case will be reviewed to determine if you meet all conditions for a Ministerial stay of removal pursuant to section 50(e) of the Immigration and Refugee Protection Act. If you are eligible, the A50(e) stay of removal will remain in effect for you and your family members residing in Canada, until the earliest of the dates set out below, or until further notice, whichever comes first:

• your PR application is "Approved in Principal",
• your application for PR status is refused, or
• IRCC, or the Ministère de l’Immigration, de la Francisation et de l’Intégration du Québec (MIFI) if you intend on residing in Québec, determines that you do not meet the eligibility criteria of the temporary public policy resulting in the refusal of your application.

The removal order will no longer be stayed if, after making your application, you or your family member, become(s) the subject of a newly issued removal order, different to the removal order that was issued as a refugee claimant, because you or your family member are inadmissible on any grounds for which you are not exempted under the temporary public policy.

Once IRCC assesses that you meet the requirements above, except for a final determination of admissibility, and concludes that you are eligible, the delegated officer will approve the application in principle under this public policy.

If you receive an approval in principle, your removal order will be stayed pursuant to section 233 of the Regulations. The stay of removal will apply until a final decision is made on the permanent residence application under this public policy.

A final assessment of admissibility will be conducted prior to granting of permanent residence.

Pre-Removal Risk Assessment (PRRA) application

If an applicant is a failed refugee claimant, and has submitted a PRRA application, the application may be held in abeyance until a final decision on the application for permanent residence under one of the public policies is made.

If the applicant received a stay of removal in the context of their PRRA as per section 232 of the Regulations, they will continue to benefit from this stay until their PRRA is resolved.

Renewal of a study or work permit

If you are applying to renew your study permit or work permit at the same time as your application for permanent residence, do not include your renewal application in the same envelope. You must pay for this application separately.

Are you inadmissible?

Reasons for inadmissibility include but are not limited to:

• criminality,
• health grounds,
• financial reasons,
• misrepresentation

If you or a family members are inadmissible for any of the following reasons you may still be approved under these public policies:

• having failed to comply with conditions related to your temporary stay including:
  • having overstayed:
    • a visa,
    • a visitor record,
    • a work permit,
    • a student permit;
• having worked or studied without being authorized to do so under the Act (as long as it was solely as a result of losing the work authorization when a removal order against you became enforceable);
• having entered Canada without the required visa or other document required under the Regulations;

• having entered Canada without a valid passport or travel document.

  Note: For the purpose of the granting of the permanent residence pursuant to this public policy, you and your family members are required by subparagraph 72(1)(e)(ii) of the Regulations to provide the Department of Immigration, Refugees and Citizenship Canada any of the documents enumerated under subsection 50(1) of the Regulations. If you and your family members in Canada are unable to obtain any of the documents, enumerated under subsection 50(1) of the Regulations (e.g, valid passport or travel document), as required by subparagraph 72(1)(e)(ii) of the Regulations, an exemption from this requirement can be granted if you can provide any of the documents described in subsection 178(1) of the Regulations if such alternative document complies with the requirement of subsection 178(2) of the Regulations.

If you or a family member is inadmissible to Canada, it is strongly suggested that you resolve your inadmissibility if possible before applying for permanent residence.

If you are inadmissible due to a criminal conviction in Canada, you may be eligible to apply for a record suspension (formerly a pardon).

If you are inadmissible due to a criminal conviction outside of Canada, you may be eligible to apply for rehabilitation.

Do you intend to reside in Quebec?

If you intend to reside in the province of Quebec, you must have a Certificat de sélection du Quebec issued under the Special program for asylum seekers during the COVID-19 period. If you meet the eligibility criteria of the public policy, you will be invited to submit the “Demande de Sélection Permanente” form and supporting documentation for selection to the Ministère de l’Immigration, de la Francisation et de l’Intégration du Québec (MIFI).

Do family members need to apply separately?

You may include your family member(s) as defined below, residing in Canada, in your application for permanent residence for concurrent processing. Your spouse or common-law partner and dependent children must be admissible (unless exempted as per above), meet all other requirements of the Act including those enumerated under subsection 50(1) of the Regulations (e.g, valid passport or travel document), as required by subparagraph 72(1)(e)(ii) of the Regulations, an exemption from this requirement can be granted if they can provide any of the documents described in subsection 178(1) of the Regulations if such alternative document complies with the requirement of subsection 178(2) of the Regulations.

Family members residing outside Canada cannot be included for concurrent processing. However, in your application, you must list all your family members residing in Canada or outside. That said, your family members residing outside Canada may be sponsored after you have become a Permanent Resident of Canada, if the requirements of the Regulations are met.

Important information: You must inform us immediately of any change in your marital status or your family composition (e.g. marriage, common-law relationship, separation, divorce, birth of a child, adoption of a child, death, etc). Any family member who has not been examined before you become a permanent resident can never be sponsored by you in the future.

Step 1. Gather documents

What documents are required?

Use the Document Checklist [IMM 1015] (opens in a new tab) to help you gather the necessary documentation.

Important information: You must provide evidence that will support any statement you make on your application.

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Reminders

It is your responsibility to ensure that the information in your application is correct and up-to-date. If your circumstances change, you must inform IRCC. Decisions made on your application will be based on the information we have at the time your application is reviewed.

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When you mail your updated information, the envelope should be clearly labelled with the words “Health-care Worker - HCW” or if you intend to reside in Quebec “Health-care Worker - HCWQC”.

Police certificate

If you and your family members are approved, you will be asked to provide additional information at a later date in order to finalize background checks.

You and your family members who are 18 years of age and older and are not permanent residents or Canadian citizens will need to provide a valid police certificate for each country other than Canada, in which you have spent six or more months cumulatively since the age of 18.

If the original certificate is not in English or French, then you will need to submit both the certificate and the original copy of the translation prepared by an accredited translator.

We will also do our own background checks to determine if there are grounds under which you and your family members may be inadmissible to Canada.

For specific and up-to-date information, see Where to get a police certificate.

Medical requirements

You and your family members must pass a medical exam in order to become a permanent resident of Canada. You or your family members must not have a condition that:

• is a danger to public health or safety, or
• would cause excessive demand on health or social services in Canada.

Instructions

Information on medical instructions will be provided to you by the IRCC office. When you receive your assessment notice you will also receive medical forms for yourself (and any family members, if applicable) and instructions on how to access a list of doctors in your area who are authorized to conduct immigration medical examinations (see below). You are not required to have a medical examination before you submit your application forms.

Exam validity

Medical results are valid for twelve months from the date of the exam. If your application is not finalized during this time, you may be required to do another medical exam.

Authorized doctors

The medical examination must be performed by a doctor from the IRCC list of Panel Physicians. You cannot choose your family doctor if their name is not on this list. See the list of Panel Physicians to find a doctor in your area.

Note that the doctor is only responsible for conducting the medical exam and cannot give you any advice on the immigration process.

Step 2. Complete the Application

Application forms to be completed

You must complete and submit the following forms:

• Document Checklist [IMM 1015] (opens in a new tab)
  • Use your checklist to make sure you include all the forms and documents you need.
  • Place the checklist on top, as a cover to your application package.
• Generic Application Form for Canada [IMM 0008] (PDF, 663 KB)
• Additional Dependants/Declaration Form [IMM 0008DEP] (PDF, 424 KB), if applicable
• Schedule A – Background/Declaration [IMM 5669] (opens in a new tab)
• Additional Family Information [IMM 5406] (opens in a new tab)
• Schedule 1 - Health-care Workers Permanent Residence Pathway (COVID-19 pandemic) [IMM 1018] (opens in a new tab)
• Use of a Representative [IMM 5476] (opens in a new tab) , if applicable
• Authority to Release [IMM 5475] (opens in a new tab), if applicable

If you intend to reside in a province or territory other than Quebec, you have until August 31, 2021, to accumulate a total of 6 months of full-time experience (30 hours per week) or 750 hours of part-time work in the designated occupation before an application can be assigned for an eligibility decision. Evidence that the experience criteria has been met must be submitted no later than October 31, 2021.

In you intend to reside in Quebec and apply under the Special program for asylum seekers during the COVID-19 period, see MIFI for more details.

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Important information

Be complete and accurate

Complete all sections. If a section does not apply to you, write “Not Applicable” or “NA”. If your application is incomplete it may be returned to you and this will delay the processing of your application.

If you need more space for any section, print out an additional page containing the appropriate section, complete it and submit it along with your application.

Generic Application Form for Canada (IMM 0008)

Who must fill out this application form?

This form must be completed by:

• you, the principal applicant

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Completing the form

You must answer all questions on this application form unless otherwise indicated.

Download and fill out the application form on a computer. The Generic Application Form for Canada [IMM 0008] must be validated with 2D barcodes.

Make sure that

• you properly validate your answers when filling out this form
• the 2D barcodes are properly generated

If the 2D barcodes are missing or can’t be machine read for any reason, the application will be returned to you without being processed.

You also have the option of saving your form and completing it later.

Read and follow the steps below to help you fill out the form.

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Application Details

Question 1

From the list, select “Other”.

Question 2

From the list, select “In Canada – Humanitarian & Compassionate Considerations”.

Question 3

Enter the total number of family members included in your application. This includes yourself and any family members, regardless of whether they intend to accompany you to Canada or not.

For refugee claimants in Canada only: Enter the total number of family members included in your application for refugee protection who are with you in Canada.

Question 4

Language preference

From the list, select your preferred language for:

1. correspondence
2. interview: if your native language is not in this list, select “other”
3. interpreter requested: you must select “yes” if you do not select English or French for the interview

Question 5

Where do you plan on living in Canada?

From the list select the:

1. Province/Territory
2. City/Town

Question 6

If you plan to live in the Province of Quebec and are applying under a Quebec immigration program, have you received your Certificat de Sélection du Québec (CSQ)?

1. Select the corresponding box
2. If you selected “Yes”, enter the CSQ number
3. If you selected “No”, enter the date when you applied for your CSQ (if you have not yet applied, please do so before applying for permanent residence)

Note: If you are not applying under a Quebec immigration program, select “no” for Question 6 a) and leave 6 c) blank.

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Principal Applicant’s Personal Details

The principal applicant must answer the following questions.

Question 1

Enter your full family name (surname or last name) as shown on your passport, travel document or identity document.

Note: If you are a parent of a child to be adopted in Canada who is not yet identified, indicate your family name(s).

Enter all of your given name(s) (first, second or more) as shown on your passport, travel document or identity document. Do not use initials.

If you don’t have a family name on your passport or travel document, enter all given names in the family name field and leave the given name field blank.

If you don’t have a given name on your passport or travel document, leave the given name field blank.

Note: If you are a parent of a child to be adopted in Canada who is not yet identified, enter “Child” or leave the given name field blank.

Question 2

Nickname/Alias

Select the box to tell us if you have ever used any other names than those indicated in question 1. This could be your birth name, maiden name, married name, nickname, etc. If “Yes,” enter your nickname/alias in the family name(s) and given name(s) fields.

Question 3

If you know your unique client identifier (UCI) number or client identification number (client ID), enter it here without any spaces. If you applied for temporary or permanent residence in the past, this is an 8 or 10 digit number you can find on previous documents sent by us. If this is your first application with us, or if you do not know your UCI, leave this space blank.

Question 4

From the list, select your gender (F – Female, M – Male or X – Another gender).

Note: If you choose the X gender identifier and you currently have or have had a Canadian temporary resident document (visa, electronic travel authorization, work permit or study permit) with a gender identifier other than X, you need to complete the Request form for a Change of Sex or Gender Identifier [IRM 0002] (PDF, 1.79 MB) form and send it with your application.

If you’ve never had a Canadian temporary resident document and your foreign travel document or passport does not contain the X gender identifier (or an equivalent non-binary option), you also need to complete the Request form for a Change of Sex or Gender Identifier [IRM 0002] (PDF, 1.79 MB) form and send it with your application.

No supporting documents are required.

Note: If you are a parent of a child to be adopted in Canada who is not yet identified, select U – Unknown.

Question 5

Enter your height in either centimetres or feet and inches.

Question 6

From the list, select your eye colour.

Note: If you are a parent of a child to be adopted in Canada who is not yet identified, select “Other.”

Question 7

Enter your date of birth. If you do not know your complete date of birth, use “01” to fill in the spaces for the unknown year, month or day. Include a letter of explanation saying why you couldn’t include the complete date.

Question 8

Enter your place of birth, including the city or town and country of birth, as shown in your passport or your travel document.

Note: If you are a parent of a child to be adopted in Canada who is not yet identified, indicate “Unknown” for the city or town and select the country where you intend to adopt a child.

Question 9

Citizenship(s)

1. From the list, select your country of citizenship.
2. If you are a citizen of more than one country, select your other country of citizenship.

Note: If you are a parent of a child to be adopted in Canada who is not yet identified, select the country where you intend to adopt a child.

Question 10

Current country of residence

From the list, select

• The name of your current country of residence. Your country of residence is the country in which you are residing, provided that you have been lawfully admitted to that country.

For refugee claimants in Canada only: select Canada whether you have been lawfully admitted or not.

• Your immigration status in that country (indicate one of the following):
  • Citizen
  • Permanent resident
  • Visitor
  • Worker
  • Student
  • Other
  • Protected Person
  • Refugee Claimant
  • Foreign National
• Other: This section must be completed if you selected “Other” as a status.
• Fill in the dates (From – To) you have been living in your current country of residence.

For out-of-status applicants

• for “Status,” select “Other”
• for “Other,” type in “Out of status, requires restoration”
• leave the “From” and “To” boxes blank

Note: If you are a parent of a child to be adopted in Canada who is not yet identified, select the country where you intend to adopt a child and “Citizen” as the immigration status in that country.

Question 11

Enter the date of your last entry to Canada, if applicable.

Enter the place you last entered Canada (for example, Toronto airport, Lacolle border crossing, seaport Yarmouth).

Question 12

Previous countries of residence

Select the box to tell us if you have lived in any country other than your country of citizenship or your current country of residence for more than 6 months in the past 5 years.

If you checked “Yes,” for each country

• select the name of the country you lived in
• select your immigration status for the time you were in that country:
  • Citizen
  • Permanent resident
  • Visitor
  • Worker
  • Student
  • Other
  • Protected Person
  • Refugee Claimant
  • Foreign National
• Other: This section must be completed if you selected “Other” as a status
• fill in the dates (From – To) you were living in that country

Question 13

1. From the list, choose your current marital status:

   Annulled Marriage

   This is a marriage that is legally declared as not valid. An annulment can also be a declaration by the Catholic Church that the marriage union did not have a binding force.

   Common-
   Law

   This means that you have lived continuously with your partner in a marital-type relationship for a minimum of 1 year.

   Divorced

   This means that you are officially separated and have legally ended your marriage.

   Legally Separated

   This means that you are married but no longer living with your spouse.

   Married

   This means that you and your spouse have had a ceremony that legally binds you to each other. Your marriage must be legally recognized in the country where it was performed and in Canada.

   Single

   This means that you have never been married and are not in a common-law relationship.

   Widowed

   This means that your spouse has died and that you have not re-married or entered into a common-law relationship.

2. Enter the date (year, month and day) you were married or you entered into your current common-law relationship.

3. Enter the family name(s) and given name(s) of your current spouse or common-law partner.

Note: If you are a parent of a child to be adopted in Canada who is not yet identified, select “Single.”

Question 14

Select the box to tell us if you have been married or in a common-law relationship. If you checked “Yes,” give the following details for your previous spouse or common-law partner:

• Family name(s)
• Given name(s)
• Type of relationship:
  • Common-law or
  • Married
• Dates (From – To) for which you were in the relationship with your previous spouse/common-law partner
• Date of birth.

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Contact Information

Question 1

Enter your current mailing address (where information should be mailed) by typing the following information:

• Post office box (P.O. box) number, if applicable. If you do not enter a post office box, you must provide the street number
• Apartment (Apt.) or Unit, if applicable
• Street number (no.), if applicable. It is the number on your house or apartment building. You must provide a street number if you did not enter in a P.O. box
• Street name, if applicable
• City or Town
• From the list, select the Country of your current mailing address
• Province or State
• Postal code or zip code
• District, if applicable

Note: All correspondence will go to this address unless you indicate your email address.

If you wish to have a representative who can conduct business on your behalf, you must provide their address in this section and on the Use of a Representative (IMM 5476) form.

For more information, read the Use of a Representative guide.

Question 2

Select the box to tell us if your residential address (where you live) is the same as your mailing address. If “No,” enter the following information:

• Apartment (Apt.) or Unit, if applicable
• Street number (no.). It is the number on your house or apartment building.
• Street name
• City or Town
• Country
• Province or State
• Postal code or zip code
• District, if applicable

Question 3

Enter your telephone number including the country code, area/regional codes, etc.

If you have an extension number, indicate it after your phone number under “Ext.”

Select the box to tell us if your telephone number is from Canada or the US or Other (any other country).

From the list, select the type of telephone:

• Residence (home)
• Cellular (cell/mobile)
• Business (work)

Question 4

If you have a second telephone number, enter it here, including the country code, area/regional codes, etc.

If you have an extension number, indicate it after your phone number under “Ext.”

Providing an alternate telephone number will help make sure we can contact you with information about your application.

Select the box to tell us if your second telephone number is from Canada or the US or Other (any other country).

From the list, select the type of telephone:

• Residence (home)
• Cellular (cell/mobile)
• Business (work)

Question 5

If you have a fax number, enter it here, including country code, area/regional codes, etc.

Select the box to tell us if the facsimile (fax) number is from Canada or the US or Other (any other country).

Question 6

If you have an email address, enter it here (for example, name@provider.net).

Note: By indicating your email address, you are hereby authorizing IRCC to transmit your file and personal information to this specific email.

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Passport

Question 1

Select the box to tell us if you have a valid passport or travel document. If you don’t have one or can’t obtain one, you must select the “No” box.

Question 2

If you select “Yes,” provide your passport or travel document number exactly as shown on the document. Make sure there is no space between each number or letter.

Question 3

From the list, select the name of the country or territory that issued your passport or travel document.

Question 4

Enter the date your passport or travel document was issued.

Question 5

Enter the date your passport or travel document will expire.

Question 6

For this trip, select Yes or No to tell us if you are using a passport issued by the Ministry of Foreign Affairs in Taiwan that shows your personal identification number.

Question 7

For this trip, select Yes or No to tell us if you are using a National Israeli passport.

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National Identity Document

Question 1

Select the box to tell us if you have a valid national identity document.

Question 2

If you selected “Yes,” provide your national identity document number exactly as shown on the identity document. Make sure there is no space between each number or letter.

Question 3

From the list, select the name of the country or territory that issued your national identity document.

Question 4

Enter the date your national identity document was issued.

Question 5

Enter the date your national identity document will expire.

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Education/Occupation Detail

Question 1

From the list, select your highest level of education.

1. None: No education
2. Secondary or less: High school diploma obtained after elementary school and before college, university, or other formal training.
3. Trade/Apprenticeship Certificate/Diploma: Diploma completed in a specific trade, such as carpentry or auto mechanics.
4. Non-University Certificate/Diploma: Training in a profession that requires formal education but not at the university level (for example, dental technician or engineering technician).
5. Post-Secondary – No Degree: Post-secondary studies at a college or university but no degree earned.
6. Bachelor’s Degree: Academic degree awarded by a college or university to those who have completed an undergraduate curriculum; also called a baccalaureate. Examples include a Bachelor of Arts, Science or Education.
7. Post Graduate – No Degree: Post-graduate studies at a college or university but no degree earned (Master or PhD).
8. Master’s Degree: Academic degree awarded by a graduate school of a college or university. You must have completed a Bachelor’s degree before a Master’s degree can be earned.
9. Doctorate – PhD: Highest university degree, usually based on at least 3 years of graduate studies and a thesis. Normally, you must have completed a Master’s degree before a PhD can be earned.

Question 2

Enter the total number of years of formal education that you have completed, including elementary and secondary school.

Question 3

Enter your current occupation.

Note: If you are a parent of a child to be adopted in Canada who is not yet identified, indicate “Unknown.”

Question 4

Enter your intended occupation in Canada.

Note: If you are a parent of a child to be adopted in Canada who is not yet identified, indicate “Unknown.”

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Language Detail

Question 1

This question is not for selection purposes. One of Canada’s immigration objectives is to support and assist the development of minority language communities in Canada.

1. From the list, select your first (native) language. This is the language that you learned at home during your childhood and that you still understand. If your native language is not in this list, select “Other.”
2. From the list, select whether you are able to communicate in English and/or French:
   • English
   • French
   • Both
   • Neither
3. If you selected “Both,” choose whether you are most at ease in English or French.
4. Select “Yes” or “No” to tell us whether you have taken a test from a designated testing agency to assess your proficiency in English or French.

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Dependant(s)

You must answer each question on behalf of each of your dependants.

To add a new dependant to the application, click the “Add Dependant” button, located at the bottom of the page.

To remove a dependant from the application, click the “Remove Dependant” button.

You can add up to 5 dependants using this form.

If you have more than 5 dependants:

To include everyone in your application, you must complete the following form for each additional family member:

• Additional Dependants/Declaration [IMM 0008DEP] (PDF, 0.42 MB)

Important

You must list all family members in your application for permanent residence, whether they are accompanying you to Canada or not. You must also provide details on family members whose location is unknown (including those missing or presumed dead). If these family members are not listed on your application, you will not be able to sponsor them at a later date.

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Dependant’s Personal Details

Questions 1–9

Questions 1 to 9 are the same questions you answered for yourself. See the previous instructions to help you answer the questions for your dependant(s).

Question 10

1. From the list, select your dependant’s relationship to you, the principal applicant:
   • Adopted Child
   • Child
   • Common-Law Partner
   • Grandchild
   • Other
   • Spouse
   • Step-Child
   • Step-Grandchild
2. Complete if you select “Other.”

Question 11

1. Select the box to tell us if your dependant will accompany you to Canada.
2. If you answered “No,” explain why your dependant is non-accompanying.

Question 12

From the list, select the type of dependant:

Type A

The dependant is under the age of 22 and single (not married and not in a common-law relationship).

Type B (Important: This dependant type applies only if your child’s age was locked in before August 1, 2014)

The dependant has been continuously enrolled in and in attendance as a full-time student at a post-secondary institution accredited by the relevant government authority and has depended substantially on the financial support of a parent since before the age of 22.

Type C

The dependant is 22 years of age or older, has depended substantially on the financial support of a parent since before the age of 22, and is unable to provide for themselves because of a medical condition.

Not sure which type of dependant your child is? Check if your child qualifies as a dependant by answering a few questions.

Question 13

Current country of residence

• From the list, select the name of your dependant’s current country of residence. The country of residence is the country in which they are residing, provided they have been lawfully admitted to that country.

For refugee claimants in Canada only: select Canada whether your dependant has been lawfully admitted or not.

• Indicate one of the following as your dependant’s immigration status in that country:
  • Citizen
  • Permanent resident
  • Visitor
  • Worker
  • Student
  • Other
  • Protected Person
  • Refugee Claimant
  • Foreign National
• Other: This section must be completed if you selected “Other” as a status.
• Fill in the dates (From – To) your dependant has been living in their current country of residence.

For out-of-status applicants

• for “Status,” select “Other”
• for “Other,” type in “Out of status, requires restoration”
• leave the “From” and “To” boxes blank

Question 14

Enter the date of your dependant’s last entry to Canada.

Tell us the place they last entered Canada (for example, Toronto airport, Lacolle border crossing, seaport Yarmouth).

Question 15

Previous countries of residence

Select the box to tell us if your dependant has lived in any country other than their country of citizenship or their current country of residence for more than 6 months in the past 5 years.

If you checked “Yes,”

• select the name of the country your dependant lived in from the list
• select your dependant’s immigration status for the time they were in that country:
  • Citizen
  • Permanent resident
  • Visitor
  • Worker
  • Student
  • Other
  • Protected Person
  • Refugee Claimant
  • Foreign National
• Other: This section must be completed if you selected “Other” as a status
• fill in the dates (From – To) your dependant was living in that country

Question 16

1. From the list, select your dependant’s current marital status:

   • Annulled Marriage
   • Common-Law
   • Divorced
   • Legally Separated
   • Married
   • Single
   • Widowed
2. Enter the date (year, month and day) your dependant was married or entered into their current common-law relationship.
3. Tell us the family name(s) and given name(s) of your dependant’s current spouse or common-law partner.

Question 17

Select the box to tell us if your dependant has previously been married or in a common-law relationship. If you selected “Yes,” give the following details for your dependant’s previous spouse or common-law partner:

• Family name(s)
• Given name(s)
• Type of relationship:
  • Common-law or
  • Married
• Dates (From – To) your dependant was in the relationship with their previous spouse or common-law partner

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Passport

Question 1

Select the box to tell us if your dependant has a valid passport or travel document. If they don’t have one or can’t obtain one, you must select the “No” box.

Question 2

If you selected “Yes,” provide their passport or travel document number exactly as shown on the document. Make sure there is no space between each number or letter.

Question 3

From the list, select the name of the country or territory that issued their passport or travel document.

Question 4

Enter the date their passport or travel document was issued.

Question 5

Enter the date their passport or travel document will expire.

Question 6

For this trip, select Yes or No to tell us if they’re using a passport issued by the Ministry of Foreign Affairs in Taiwan that shows their personal identification number.

Question 7

For this trip, select Yes or No to tell us if they’re using a National Israeli passport.

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National Identity Document

Question 1

Select the box to tell us if your dependant has a valid national identity document.

Question 2

If you selected “Yes,” provide their national identity document number exactly as shown on the document. Make sure there is no space between each number or letter.

Question 3

From the list, select the name of the country or territory that issued their national identity document.

Question 4

Enter the date their national identity document was issued.

Question 5

Enter the date their national identity document will expire.

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Education/Occupation Detail

Question 1

From the list, select your dependant’s highest level of education.

• None: No education
• Secondary or less: High school diploma obtained after elementary school and before college, university, or other formal training.
• Trade/Apprenticeship Certificate/Diploma: Diploma completed in a specific trade, such as carpentry or auto mechanics.
• Non-university Certificate/Diploma: Training in a profession that requires formal education but not at the university level (for example, dental technician or engineering technician).
• Post-Secondary – No Degree: Post-secondary studies at a college or university but no degree earned.
• Bachelor’s Degree: Academic degree awarded by a college or university to those who have completed an undergraduate curriculum; also called a baccalaureate. Examples include a Bachelor of Arts, Science or Education.
• Post Graduate – No Degree: Post-graduate studies at a college or university but no degree earned (Master or PhD).
• Master’s Degree: Academic degree awarded by a graduate school of a college or university. You must have completed a Bachelor’s degree before a Master’s degree can be earned.
• Doctorate – PhD: Highest university degree, usually based on at least 3 years of graduate studies and a thesis. Normally, you must have completed a Master’s degree before a PhD can be earned.

Question 2

Tell us the total number of years of formal education that they have completed, including elementary and secondary school.

Question 3

Tell us their current occupation.

Question 4

Tell us their intended occupation in Canada.

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Language Detail

Question 1

This question is not for selection purposes. One of Canada’s immigration objectives is to support and assist the development of minority language communities in Canada.

1. From the list, select your dependant’s first (native) language. This is the language that they learned at home during their childhood and they still understand. If their native language does not appear in this list, select “Other.”

Note: If you are a parent of a child to be adopted in Canada who is not yet identified, select the native language of the country where you intend to adopt a child.

2. From the list, select if they are able to communicate in English and/or French:
   • English
   • French
   • Both
   • Neither
3. If you selected “Both,” choose whether they are most at ease in English or French.
4. Select “Yes” or “No” to tell us whether they have taken a test from a designated testing agency to assess their proficiency in English or French.

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Consent and Declaration of Applicant

1. Once the application is completed, click on the “Validate” button located at the top or bottom of the form. This will generate a barcode page or pages (see image below).

   

   Note: This barcode page will not appear if you fill out your application by hand.

2. Print all pages of your application form.

3. Read all of the statements in all sections carefully and

   1. write your name in the space provided.
   2. check the appropriate box to indicate if you agree that the information contained in this application related to your intended occupation, education and work experience may be shared with prospective employers in order to assist them in hiring workers
   3. sign, with a handwritten signature, and date in the spaces provided

   By signing, you certify that you fully understand the questions asked, and that the information you have provided is complete, truthful, and correct. If you do not sign and date, the application will be returned to you.

4. Place the barcode page(s) on the top of your application (forms and supporting documents) when you submit it.

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Additional Dependants/Declaration (IMM 0008DEP)

Who must fill out this application form?

This form must be completed by

• you, the principal applicant, on behalf of each of your dependants not included in the Generic Application Form for Canada (IMM 0008).

The questions are the same as the ones that you answered for yourself and other dependants on the IMM 0008 form.

Follow the previous instructions to help you answer the questions.

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Consent and Declaration of Applicant

Read all of the statements in all sections carefully and then

1. write your dependant’s name in the space provided
2. select the box to tell us if you agree that the information contained in this application related to your dependant’s intended occupation, education and work experience may be shared with prospective employers to assist them in hiring workers
3. sign and date in the spaces provided

By signing, you certify that your dependant fully understands the questions asked, and that the information you have provided is complete, truthful, and correct. If you do not sign and date, the application will be returned to you.

Step 3. Pay the fees

Your fees

Use the table below to calculate the total amount of fees to be paid. The processing fee must be included with your application.

We recommend you pay the right of permanent residence fee ($500) now to avoid delays. You will have to pay it before you become a permanent resident.

Important information

The only acceptable form of payment is online payment. If you send any other form of payment, IRCC will return your application.

Payment for any other type of application cannot be included with this application. Any other application (i.e. renewal of temporary resident status) must be sent to the appropriate processing centre and paid for separately.

Step 4. Mail your application

Where to mail the application?

Important information

Your application must be submitted no later than August 31, 2021.

If you intend to reside in a province or territory other than Quebec

• You have until August 31, 2021, to accumulate a total of 6 months of full-time experience (30 hours per week) or 750 hours of part-time work in the designated occupation.
• Evidence that the experience criteria has been met must be submitted no later than October 31, 2021. That said, applicants who complete their work experience prior to August 31, 2021, are expected to submit evidence within 60 days of completion. Use the Document Checklist [IMM 1015] (opens in a new tab) to help you gather the necessary documentation for you work experience.

If you meet the eligibility criteria of the public policy, you will be invited to submit the “Demande de Sélection Permanente” form and supporting documentation for selection under the Special program for asylum seekers during the COVID-19 period to the Ministère de l’Immigration, de la Francisation et de l’Intégration du Québec (MIFI).

When you mail your application, the envelope should be clearly labelled with the words “Health-care Worker - HCW” or if you intend to reside in Quebec “Health-care Worker - HCWQC”.

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Mail your completed application in a stamped envelope to the address shown below:

Applicants intending to reside in a province or territory other than Quebec

Updated information and proof of a total of 6 months of full-time experience (30 hours per week) or 750 hours of part-time work should be sent to the Humanitarian Migration Office in Vancouver by fax at 604-666-1116, or by mail.

Submit the document checklist

Make sure you use and submit the Document Checklist [IMM 1015] (opens in a new tab) along with your application forms and supporting documents.

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Mail your application

Do not fold documents.

For your personal records, you should make photocopies of all documentation, forms and your fee receipt submitted with your application.

Do not include pre-paid return envelopes.

You may want to send your application via registered mail or Xpresspost to track the delivery.

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What Happens Next

What you will receive from IRCC

The following table outlines the type of communication that you may receive from IRCC as a result of submitting this application.

• If your application is received and properly completed

  • your application will be processed.

    Note: We may contact you to verify or expand on information contained in your application.

• If your application is received and incomplete
  • your application will be returned to you.
• If your application is approved
  • we will inform you in writing and provide further information on the next steps to proceed to obtain your permanent residence status (i.e. medical instructions, background checks).
• If your application is refused
  • we will inform you in writing.
• If your application is received with insufficient or non-payment of fees
  • we will not process your application and it will be returned to you with further instructions.

Withdrawing the application

If you wish to withdraw your application, you must do so in writing. Make sure to indicate your Unique Client Identification (UCI) number, family name and first name on all correspondence with IRCC.

You must send your notification by fax at 604-666-1116 or by mail at:

Humanitarian Migration Office - Vancouver
300 - 800 Burrard Street
Vancouver, B.C.
V6Z 0B6

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Checking application status

In Canada and the United States

You may Contact Us or go online to see the current status of your application:

1. Click on Check application status, and
2. Follow the instructions provided.

If you are outside Canada and the United States:

Contact the Canadian embassy, high commission or consulate responsible for your region

Appendix A: Police Certificates

Request for Police Certificates/Clearances and Authorization for Release of Information (PDF, 58.59 KB)

Text version: Request for Police Certificates/Clearances and Authorization for Release of Information

• Surname
• Given name(s)
• Other surname(s) used (example maiden name, previous married names)
• Name in original script (example Farsi, Arabic, Chinese, etc.)
• Date of birth (day, month, year)
• Place of birth
• Sex (male, female)
• Citizenship
• Current address in Canada (number, street, city, province and postal code)
• Dates
  • From (month, year)
  • To (month, year)
• Address(es) while resident in (name of country)

I authorize the police or relevant authorities in the country/state named above to disclose to Immigration Canada details about any previous criminal convictions that may exist.

• Signature of applicant
• Date (Day, Month, Year)