Canada IMM5257B Schedule 1 Form

Citizenship and Citoyenneté et PROTECTED WHEN COMPLETED - B
Immigration Canada 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 there is not enough space to provide all the necessary information,
if applicable, and all dependent children aged 18 years or older attach to this form a separate sheet of paper with further details. Print
listed in the application for temporary residence must complete your name at the top of each additional sheet and indicate the form's
their own copy of this form. 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
The spouse, common-law partner or dependent child

Indicate whether you are The principal applicant
aged 18 years or older of the principal applicant
1 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 Yes Give the following details:

From To
Location/Place where stationed Province Country
Y M Y M
4 Have you ever witnessed or participated in the ill treatment of prisoners or civilians, looting or desecration of religious buildings?
No Yes Provide details of the circumstances below:
From To
Location Province Country
Y M Y M
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 To Activities and/or positions held

Name of organization Province Country
Y M Y M within organization
IMM 5257 (06-2012) E This form is made available by Citizenship and Immigration Canada and is not to be sold to applicants.
Schedule 1 (AUSSI DISPONIBLE EN FRANÇAIS - IMM 5257 F - Annexe 1)
PAGE 2 OF 2
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 To Country and level of jurisdiction

Y M Y M Department/Branch Activities and/or positions held
(e.g. national, regional, municipal)
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.
Year Month Day
Signature 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 Interpreter declaration
I, , I, ,
do solemnly declare that the information I have given in the foregoing do solemnly declare that I have faithfully and accurately interpreted in the
application is truthful, complete and correct, and I make this solemn
declaration conscientiously believing it to be true and knowing that it is of language the content of this
the same force and effect as if made under oath. 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 Signature of
applicant interpreter
Declared of the year

this day of
before me at (YYYY)
Canadian
Government Name Signature
Official
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.
IMM 5257 (06-2012) E

Schedule 1

Canada IMM5257B Schedule 1 Form

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Citizenship and Citoyenneté et PROTECTED WHEN COMPLETED - B

Immigration Canada Immigration Canada

BEFORE YOU START, READ THE INSTRUCTION GUIDE

The spouse, common-law partner or dependent child

1 Your full name

2 Year Month Day

Your date of birth

No Yes Give the following details:

5 Membership or association with organizations

No Yes Give the following details:

From To Activities and/or positions held

No Yes Give the following details:

From To Country and level of jurisdiction

Authority to disclose personal information

Solemn declaration Interpreter declaration

I have been informed by the person concerned, and I do verily believe,

Declared of the year

IMM 5257 (06-2012) E

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