I may be inadmissible to Canada because of the following offence(s):
Explain in detail the events/circumstances leading to the offence(s)/conviction(s).
DETAILS OF ALL OFFENCES AND CONVICTIONS MUST BE ACCURATELY RECORDED ON THIS
DOCUMENT. PROVIDING FALSE OR MISLEADING INFORMATION WILL LIKELY RESULT IN A
REFUSAL OF YOUR APPLICATION AND MAY PERMANENTLY BAR YOUR ADMISSION TO CANADA.
Explain in detail the events/circumstances leading to the offence(s)/conviction(s).
Provide reasons why you consider yourself to be rehabilitated and why you do not represent
a risk to public safety.
Addresses since the age of 18.
Forms will be returned if there is any period of time for which you have not shown
an address. Do not use post office (P.O.) box addresses.
Provide the details of your employment history since the age of 18. Start with the most recent
information. Under “OCCUPATION”, write your occupation or job tittle if you were working. If
you were not working, provide information on what you were doing (for example: unemployed,
studying, traveling, in detention, etc.)
Note: Please ensure that you do not leave any gaps in time.
Failure to account for all time periods will result in a delay in the proccessing of
your application.
THE INFORMATION YOU PROVIDE IN THIS DOCUMENT IS COLLECTED UNDER THE AUTHORITY OF
THE CANADA IMMIGRATION AND REFUGEE PROTECTION ACT AND IS STORED IN PERONAL
INFORMATION BANK NUMBER CIC PPU 042, 054 OR 300. THE INFORMATION IS PROTECTED
UNDER THE PROVISIONS OF THE PRIVACY ACT AND IS ACCESSIBLE TO YOU UPON REQUEST.
I certify that the information provided by me is true and complete to the best of my knowledge.
I also certify that I am not currently charged with any criminal offence.
