canada imm5257b schedule 1 form

Citizenship and Immigration Canada

Citoyennet et Immigration Canada

PAGE 1 OF 2

IMM 5257 (06-2012) E Schedule 1

PROTECTED WHEN COMPLETED - B

This form is made available by Citizenship and Immigration Canada and is not to be sold to applicants. (AUSSI DISPONIBLE EN FRANAIS - IMM 5257 F - Annexe 1)

SCHEDULE 1 APPLICATION FOR TEMPORARY RESIDENT VISA

The principal applicant, his or her spouse or common-law partner, if applicable, and all dependent children aged 18 years or older listed in the application for temporary residence must complete their own copy of this form.

If there is not enough space to provide all the necessary information, attach to this form a separate sheet of paper with further details. Print your name at the top of each additional sheet and indicate the form's title and the number of the question you are answering.

Before you start completing this form, make enough photocopies for your needs. You can also print all or part of this form from our Web site at www.cic.gc.ca.

BEFORE YOU START, READ THE INSTRUCTION GUIDE TYPE or PRINT in black ink

Indicate whether you are The principal applicant The spouse, common-law partner or dependent child aged 18 years or older of the principal applicant

1 Your full nameFamily name Given name(s)

3 Military Service Did you serve in any military, militia, or civil defence unit or serve in a security organization or police force (including non obligatory national service, reserve or volunteer units)?

YesNo Give the following details:

FromY M

ToY M

Location/Place where stationed Province Country

Canada places a high value on bringing those who commit acts of genocide, war crimes or crimes against humanity to justice. Canada was the first country to incorporate the obligations of the Rome Statute into its national laws.

Year DayMonth

Your date of birth

2

Have you ever witnessed or participated in the ill treatment of prisoners or civilians, looting or desecration of religious buildings?4

YesNo Provide details of the circumstances below:

FromY M

ToY M

Location Province Country

Additional details

5 Membership or association with organizations Are you, or have you ever been a member or associated with any political party, or other group or organization which has engaged in or advocated violence as a means to achieving a political or religious objective, or which has been associated with criminal activity at any time? Do not use abbreviations.


FromY M

ToY M

Name of organization Activities and/or positions held within organization Province Country

OF 2

IMM 5257 (06-2012) E Schedule 1

6 Government positions Have you ever held any government positions (such as civil servant, judge, police officer, mayor, member of parliament, hospital administrator)? Do not use abbreviations.

FromY M

ToY M

Country and level of jurisdiction (e.g. national, regional, municipal) Department/Branch Activities and/or positions held


Authority to disclose personal information By submitting this form, you consent to the release to Canadian government authorities of all records and information any government authority, including police, judicial and state authorities in all countries in which you have lived may possess on your behalf concerning any investigations, arrests, charges, trials, convictions and sentences. This information will be used to assist in evaluating your suitability for admission to Canada or remaining in Canada pursuant to Canadian legislation.

Declaration of applicant I, (your full name), , declare that all of the above statements are true, complete and correct, and I make this declaration knowing that it is of the same effect as if made before a court of law. Signature

Year DayMonth

Date

DO NOT COMPLETE THE FOLLOWING SECTION NOW. YOU MAY BE ASKED TO SIGN IN THE PRESENCE OF A REPRESENTATIVE OF THE CANADIAN GOVERNMENT OR AN OFFICIAL APPOINTED BY THE CANADIAN GOVERNMENT.

Solemn declaration I, , do solemnly declare that the information I have given in the foregoing application is truthful, complete and correct, and I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath. Signature of applicant

Interpreter declaration I, , do solemnly declare that I have faithfully and accurately interpreted in the language the content of this application and any related forms to the person concerned. I have been informed by the person concerned, and I do verily believe, that he or she completely understands the nature and effect of these forms, and I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as is made under oath. Signature of interpreter

Declared before me at this day of

of the year (YYYY)

Name Signature

Canadian GovernmentOfficial

Please print or type

The information you provide on this form is collected under the authority of the Immigration and Refugee Protection Act and will be used for the purpose of assessing your application for permanent residence. It will be stored in Personal Information Banks (PPU 039 entitled Overseas Immigration Case File and PPU 042 entitled Immigrant Case File). It may be shared with other organizations in accordance with the consistent use of information under the Privacy Act. Under the provisions of the Privacy Act and the Access to Information Act, individuals have the right to protection of and access to their personal information. Details on these matters are available at the Infosource website (http://infosource.gc.ca) and are also available at public libraries across Canada.

Citizenship and

Immigration Canada

Citoyennet et

Immigration Canada

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PAGE OF

Schedule 1

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PROTECTED WHEN COMPLETED -B

This form is made available by Citizenship and Immigration Canada and is not to be sold to applicants.

(AUSSI DISPONIBLE EN FRANAIS - IMM 5257 F - Annexe 1)

PAGE OF

Schedule 1

SCHEDULE 1

APPLICATION FOR TEMPORARY RESIDENT VISA

The principal applicant, his or her spouse or common-law partner,

if applicable, and all dependent children aged 18 years or older

listed in the application for temporary residence must complete

their own copy of this form.

If there is not enough space to provide all the necessary information,

attach to this form a separate sheet of paper with further details. Print

your name at the top of each additional sheet and indicate the form's

title and the number of the question you are answering.

Before you start completing this form, make enough photocopies for your needs. You can also print all or part of this form from our Web site at

www.cic.gc.ca.

BEFORE YOU START, READ THE INSTRUCTION GUIDE

TYPE or PRINT in black ink

Indicate whether you are

..\..\..\Graphics\ARROW.tif

1

Your full name

3

Military Service

Did you serve in any military, militia, or civil defence unit or serve in a security organization or police force (including non obligatory national service, reserve or volunteer units)?


Give the following details:

From

Y

M

To

Y

M

Location/Place where stationed

Province

Country

Canada places a high value on bringing those who commit acts of genocide, war crimes or crimes against humanity to justice. Canada was the first country to incorporate the obligations of the Rome Statute into its national laws.

Year

Day

Month

2

Have you ever witnessed or participated in the ill treatment of prisoners or civilians, looting or desecration of religious buildings?

4


Provide details of the circumstances below:

From

Y

M

To

Y

M

Location

Province

Country

Additional details

5

Membership or association with organizations

Are you, or have you ever been a member or associated with any political party, or other group or organization which has engaged in or advocated violence as a

means to achieving a political or religious objective, or which has been associated with criminal activity at any time? Do not use abbreviations.



From

Y

M

To

Y

M

Name of organization

Activities and/or positions held

within organization

Province

Country

6

Government positions

Have you ever held any government positions (such as civil servant, judge, police officer, mayor, member of parliament, hospital administrator)? Do not use abbreviations.

From

Y

M

To

Y

M

Country and level of jurisdiction

(e.g. national, regional, municipal)

Department/Branch

Activities and/or positions held



Authority to disclose personal information

By submitting this form, you consent to the release to Canadian government authorities of all records and information any government authority, including police,

judicial and state authorities in all countries in which you have lived may possess on your behalf concerning any investigations, arrests, charges, trials, convictions

and sentences. This information will be used to assist in evaluating your suitability for admission to Canada or remaining in Canada pursuant to Canadian

legislation.

Declaration of applicant

I, (your full name), , declare that all of the above statements are true, complete and correct, and

I make this declaration knowing that it is of the same effect as if made before a court of law.

Signature


Year

Day

Month

DO NOT COMPLETE THE FOLLOWING SECTION NOW.YOU MAY BE ASKED TO SIGN IN THE PRESENCE OF A

REPRESENTATIVE OF THE CANADIAN GOVERNMENT OR AN OFFICIAL APPOINTED BY THE CANADIAN GOVERNMENT.

Solemn declaration

I, , do solemnly declare that the information I have given in the foregoing application is truthful, complete and correct, and I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath.

Signature of

applicant


Interpreter declaration

I, , do solemnly declare that I have faithfully and accurately interpreted in the

language the content of this application and any related forms to the person concerned.

I have been informed by the person concerned, and I do verily believe, that he or she completely understands the nature and effect of these forms, and I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as is made under oath.

Signature of

interpreter




Signature

Canadian

Government

Official

Please print or type

The information you provide on this form is collected under the authority of theImmigration and Refugee Protection Actand will be used for the purpose of assessing your application for permanent residence. It will be stored in Personal Information Banks (PPU 039 entitled Overseas Immigration Case File and PPU 042 entitled Immigrant Case File). It may be shared with other organizations in accordance with the consistent use of information under thePrivacy Act. Under the provisions of thePrivacy Actand theAccess to Information Act, individuals have the right to protection of and access to their personal information. Details on these matters are available at the Infosource website (http://infosource.gc.ca) and are also available at public libraries across Canada.




IMM 5257E Schedule 1 : Application for a Temporary Resident Visa Made Outside Canada

06-2012

E
CurrentPage: PageCount: formNum: IMM 5257 (06-2012) Eapplicant: spouse: familyName: givenName: YesButton: NoButton: TextField1: d: Enter as YYYY-MM-DD, or click the down arrow to open the calendar. Entrez sous la forme AAAA-MM-JJ, ou cliquez sur la flche pour ouvrir le calendrier.: text:

canada imm5257b schedule 1 form

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