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IMM 5257 (06-2012) E
Have you ever held any government positions (such as civil servant, judge, police officer, mayor, member of parliament, hospital administrator)? Do not use
Country and level of jurisdiction
(e.g. national, regional, municipal)
Department/Branch Activities and/or positions held
Give the following details:
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
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.
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.
do solemnly declare that the information I have given in the foregoing
application is truthful, complete and correct, 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.
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.
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
before me at
this day of
of the year
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.