Citizenship andImmigration Canada PROTECTED WHEN COMPLETED - B Citoyenneté et Immigration Canada PAGE 1 OF 2 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 1 The spouse, common-law partner or dependent child aged 18 years or older of the principal applicant The principal applicant Indicate whether you are Your full name Family name Given name(s) 2 Year Month Day Your date of birth 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. 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)? No To From Y 4 Give the following details: Yes M Y Location/Place where stationed M Province Country Have you ever witnessed or participated in the ill treatment of prisoners or civilians, looting or desecration of religious buildings? No Yes From Y Provide details of the circumstances below: To M Y Province Location M 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. No Yes From Y Give the following details: To M IMM 5257 (06-2012) E Schedule 1 Y M Name of organization Activities and/or positions held within organization Province This form is made available by Citizenship and Immigration Canada and is not to be sold to applicants. (AUSSI DISPONIBLE EN FRANÇAIS - IMM 5257 F - Annexe 1) Country .PAGE 2 OF 2 6 Government positions Have you ever held any government positions (such as civil servant. IMM 5257 (06-2012) E Schedule 1 . hospital administrator)? Do not use abbreviations. that he or she completely understands the nature and effect of these forms. municipal) Department/Branch Activities and/or positions held Authority to disclose personal information By submitting this form. arrests. Under the provisions of the Privacy Act and the Access to Information Act. national.ca) and are also available at public libraries across Canada. do solemnly declare that the information I have given in the foregoing application is truthful. member of parliament. mayor. regional. including police. It may be shared with other organizations in accordance with the consistent use of information under the Privacy Act. Signature of applicant Signature of interpreter Declared before me at Canadian Government Official this Name day of of the year (YYYY) Signature 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. 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. police officer. and I do verily believe. judicial and state authorities in all countries in which you have lived may possess on your behalf concerning any investigations. complete and correct. trials. I have been informed by the person concerned. YOU MAY BE ASKED TO SIGN IN THE PRESENCE OF A REPRESENTATIVE OF THE CANADIAN GOVERNMENT OR AN OFFICIAL APPOINTED BY THE CANADIAN GOVERNMENT. 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. Declaration of applicant I.gc. Solemn declaration Interpreter declaration I. This information will be used to assist in evaluating your suitability for admission to Canada or remaining in Canada pursuant to Canadian legislation. Details on these matters are available at the Infosource website (http://infosource. convictions and sentences. (your full name).g. and I make this declaration knowing that it is of the same effect as if made before a court of law. No From Y Yes M Y Give the following details: To M Country and level of jurisdiction (e. It will be stored in Personal Information Banks (PPU 039 entitled Overseas Immigration Case File and PPU 042 entitled Immigrant Case File). you consent to the release to Canadian government authorities of all records and information any government authority. declare that all of the above statements are true. . judge. . charges. I. individuals have the right to protection of and access to their personal information. 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. complete and correct. Year Signature Month Day Date DO NOT COMPLETE THE FOLLOWING SECTION NOW.