(DISPONIBLE EN FRANÇAIS - PPTC 057 F)

PROTECTED WHEN COMPLETED - B

Page of

ADDITIONAL INFORMATION DOCUMENTS TO SUPPORT IDENTITY AND REFERENCES

PPTC 057 (01-2019) E

File number:

WARNING—Any false or misleading statement with respect to this form and any supporting document, including the concealment of any material fact, may result in the refusal to issue a passport, the revocation of a currently valid passport, or the refusal of passport services, and may be grounds for criminal prosecution. Your application will not be processed if you fail to complete all of the required sections of this form and/or refuse to consent to the exchange or disclosure of any personal information required for the delivery of passport services.

TYPE OR PRINT IN CAPITAL LETTERS using black or dark blue ink.

APPLICANT'S PERSONAL INFORMATION

Surname (last name) Given name(s) Date of birth (YYYY-MM-DD)

DOCUMENTS TO SUPPORT IDENTITYProvide at least one (1) document to support your identity with the name to appear in the passport. Copies are acceptable provided your guarantor has signed and dated a copy of each document (both sides) confirming that the original document has been seen.

1 Type of document Document numberDate of expiry, if applicable (YYYY-MM-DD) Your name as it appears on the document

2 Type of document Document numberDate of expiry, if applicable (YYYY-MM-DD) Your name as it appears on the document

REFERENCESProvide the following information with respect to two (2) persons who are neither your relatives nor your guarantor and who have known you for at least two (2) years. They may be contacted to confirm your identity.

1

Surname (last name) Given name(s)

Relationship Address (Number, Street, Apartment, City, Province/Territory/State, Country, Postal/ZIP Code)

Daytime telephone number Evening telephone number Cell number or email address (optional) Has known me for

Number or years

2

Surname (last name) Given name(s)

Relationship Address (Number, Street, Apartment, City, Province/Territory/State, Country, Postal/ZIP Code)

Daytime telephone number Evening telephone number Cell number or email address (optional) Has known me for

Number or years

DECLARATION OF APPLICANTDECLARATION—I solemnly declare that I am a Canadian citizen and that all of the statements made and the information provided in this form, as well as any supporting documents, are true. I declare that I have read and understood the Warning at the top of this page and the Privacy Notice Statement listed in the Instructions for the passport application form to which this form relates (see section N). I consent to the collection, use and disclosure of my personal information by the Passport Program, Immigration, Refugees and Citizenship Canada, other federal government institutions, Government of Canada offices abroad and third party entities as outlined in the Privacy Notice Statement.

Signature of applicant Date (YYYY-MM-DD)

Signed at

City Country

(DISPONIBLE EN FRANÇAIS - PPTC 057 F)

Government of Canada

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PROTECTED WHEN COMPLETED - B

Page  of 

ADDITIONAL INFORMATION

DOCUMENTS TO SUPPORT IDENTITY AND REFERENCES

PPTC 057 (01-2019) E

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Page  of 

WARNING—Any false or misleading statement with respect to this form and any supporting document, including the concealment of any material fact, may result in the refusal to issue a passport, the revocation of a currently valid passport, or the refusal of passport services, and may be grounds for criminal prosecution. Your application will not be processed if you fail to complete all of the required sections of this form and/or refuse to consent to the exchange or disclosure of any personal information required for the delivery of passport services.

WARNING—Any false or misleading statement with respect to this form and any supporting document, including the concealment of any material fact, may result in the refusal to issue a passport, the revocation of a currently valid passport, or the refusal of passport services, and may be grounds for criminal prosecution. Your application will not be processed if you fail to complete all of the required sections of this form and/or refuse to consent to the exchange or disclosure of any personal information required for the delivery of passport services.

TYPE OR PRINT IN CAPITAL LETTERS using black or dark blue ink.

TYPE OR PRINT IN CAPITAL LETTERS using black or dark blue ink.

APPLICANT'S PERSONAL INFORMATION

Section 1: Applicant's personal information

DOCUMENTS TO SUPPORT IDENTITY

Section 2: Documents to support identity

Provide at least one (1) document to support your identity with the name to appear in the passport. Copies are acceptable provided your guarantor has signed and dated a copy of each document (both sides) confirming that the original document has been seen.

Provide at least one (1) document to support your identity with the name to appear in the passport. Copies are acceptable provided your guarantor has signed and dated a copy of each document (both sides) confirming that the original document has been seen.

1

Document to support identity 1

2

Document to support identity 2

REFERENCES

Section 3: References

Provide the following information with respect to two (2) persons who are neither your relatives nor your guarantor and who haveknown you for at least two (2) years. They may be contacted to confirm your identity.

Provide the following information with respect to two (2) persons who are neither your relatives nor your guarantor and who have

known you for at least two (2) years. They may be contacted to confirm your identity.

1

Reference 1

Number or years

2

Reference 2

Number or years

DECLARATION OF APPLICANT

Section: Declaration of Applicant

DECLARATION—I solemnly declare that I am a Canadian citizen and that all of the statements made and the information provided in this form, as well as any supporting documents, are true. I declare that I have read and understood the Warning at the top of this page and the Privacy Notice Statement listed in the Instructions for the passport application form to which this form relates (see section N). I consent to the collection, use and disclosure of my personal information by the Passport Program, Immigration, Refugees and Citizenship Canada, other federal government institutions, Government of Canada offices abroad and third party entities as outlined in the Privacy Notice Statement.

DECLARATION—I solemnly declare that I am a Canadian citizen and that all of the statements made and the information provided in this form, as well as any supporting documents, are true. I declare that I have read and understood the Warning at the top of this page and the Privacy Notice Statement listed in the Instructions for the passport application form to which this form relates (see section N). I consent to the collection, use and disclosure of my personal information by the Passport Program, Immigration, Refugees and Citizenship Canada, other federal government institutions, Government of Canada offices abroad and third party entities as outlined in the Privacy Notice Statement.

Signed at

6.3.0.20170316.1.928536.925622

Information Management Directorate

Immigration, Refugees and Citizenship Canada

Immigration, Refugees and Citizenship Canada

PPTC 057 E : Additional information - Documents to support identity and References

12-2018

E

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