Phone Last Name * First Name * Date Of Birth * Nickname, maiden name or alias Sex * Select Male Female Height cm, ft, inch Eye Color Place of Birth Citizenship * Current Residence Country * Residence State * Residence From yyyy-dd-mm Residence To yyyy-mm-dd Date and place of your last entry to Canada yyyy-dd-mm | place name Language Preference Where do you intend to live in Canada? Funds (Amount of unencumbered transferable and available funds you have, in Canadian dollars) Visa requested * Transit Visa Visitor Visa Previous countries of residence: During the past five years have you lived in any country other than your country of citizenship or your current country of residence (indicated above) for more than six months? Previous countries of residence * Select Yes No Country Country Status From yyyy-mm-dd To yyyy-mm-dd Country or territory where applying: Same as current country or territory of residence? Same as current country or territory of residence Select Yes No Country or territory Status From yyyy-mm-dd To yyyy-mm-dd Marital status * Select married unmarried live in relationship single Date Provide the date on which you were married or entered into the common-law relationship Provide the name of your current spouse/common-law partner Have you previously been married or in a common-law relationship? Select Yes No if yes fill information below Provide the following details of your previous spouse/common-law partner: Name Date of Birth Relationship From Relationship To Contact Detail Country State / Province Postal Code Town Street Name or Landmark Residential Address don't fill if same as mailing address Country State / Province Postal Code Town Street Name or Landmark Telephone * Alternate Telephone * Email Passport or Travel Documents Passport/Travel document number (exactly as shown on your passport or travel document) Issue Date Expire Date If you have a national identity document Document number Country of Issue Issue Date Expiry Date Language Detail Native Language/Mother Tonue Are you able to communicate in English and/or French? In which language are you most at ease? Details of Visit to Canada Purpose of my visit to Canada Indicate how long you plan to stay From (yyyy-mm-dd) Indicate how long you plan to stay To (yyyy-mm-dd) Funds available for my stay Name, address and relationship of any person (s) or institution (s) I will visit: Name Relationship Address Additional Family Information Relationship Name Country of Birth Other Info Employment From To Activity / Occupation Employer Details Education From To Field and Level of Study Institute Address province or state, country Background Information 1. a) Within the past two years, have you or a family member ever had tuberculosis of the lungs? b) Do you have any physcial or mental disorder that would require social and/or health services, other than medication, during a stay in Canada? c) Please provide details and the name of the family member If you answered "yes" to question 1 a) or b) 2 a) Have you ever remained beyond the validity of your status, attended school without authorization or worked without authorization in Canada? b) Have you ever been refused a visa or permit, denied entry or ordered to leave Canada or any other country or territory? c) Have you previously applied to enter or remain in Canada? 3 a) Have you ever committed, been arrested for, been charged with or convicted of any criminal offence in any country or territory? 4 a) Did you serve in any military, militia, or civil defence unit or serve in a security organization or police force? 5 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? 6 Have you ever witnessed or participated in the ill treatment of prisoners or civilians, looting or desecration of religious buildings?
