Citoyenneté et
Immigration Canada
Citizenship and
Immigration Canada
PAGE # OF ##
PROTECTED WHEN COMPLETED -
B
IMM 5257 (02-2015)
Schedule 1
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)
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.
*Indicate whether you are
The principal applicant
The spouse, common-law partner or dependent child aged 18 years or
older of the principal applicant
Validated
OFFICE USE ONLY
1
Full name
*Family name (as shown on your passport or travel document) Given name(s) (as shown on your passport or travel document)
*Date of birth
YYYY DDMM
2
UCI
3
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.
4
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)?
*Yes*No
Give the following details:
From
YYYY
MM
YYYY
To
MM
Location/Place where stationed Province Country
Add more rows
5
Have you ever witnessed or participated in the ill treatment of prisoners or civilians, looting or desecration of religious buildings?
*Yes*No
Give the following details:
YYYY MM
From
YYYY
To
MM
Location Province Country
Details:
Details:
Details:
Validate
Clear Form
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Citoyenneté et
Immigration Canada
Citizenship and
Immigration Canada
PAGE # OF ##
PROTECTED WHEN COMPLETED -
B
IMM 5257 (02-2015)
Schedule 1
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)
Add more rows
6
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.
*Yes*No
Give the following details:
YYYY
MM
From
YYYY
To
MM
Name of organization
Activities and/or positions held
within organization
Province Country
Add more rows
7
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.
*Yes*No
Give the following details:
YYYY MM
From
YYYY
To
MM
Country
Level of jurisdiction
(e.g. national, regional,
municipal)
Department/Branch
Activities and/or
positions held
Add more rows
8
Previous Travel
Since the age of 18 or during the past five years, whichever is more recent, have you travelled to any country other than the country of your citizenship or your current country of
residence?
*Yes*No
Give the following details:
YYYY MM
From
YYYY
To
MM
Country Location Purpose of Travel
Add more rows
The information you provide to CIC is collected under the authority of IRPA to determine if you may be admitted to Canada as a visitor. The information may be shared with other organizations such as CBSA, DFAIT, RCMP, CSIS
and foreign governments in accordance with subsection 8(2) of the Privacy Act. Information may also be disclosed to foreign governments, law enforcement bodies and detaining authorities with respect to the administration
and enforcement of immigration legislation where such sharing of information may not put the individual and or his/her family at risk. Information may also be systematically validated by other Canadian government
institutions under the terms of an agreement or arrangement for the purposes of validating status and identity to administer their programs.
If you are required to provide biometric information to accompany your application, the fingerprints collected will be stored and shared with the RCMP and the fingerprint record may also be disclosed to law enforcement
agencies in Canada in accordance with subsection 13.11 of the Immigration and Refugee Protection Regulations. This information may be used in relation to an offence under any law of Canada or a province for the purposes of
establishing or verifying the identity of an individual, or to establish or verify the identity of an individual whose identity cannot reasonably be otherwise established or verified because of physical or mental condition.
The information you provide to CIC will be stored in the Personal Information Bank (PIB) CIC PPU (039 and 055). If you are required to provide biometric information, your fingerprints shared with the RCMP will be stored in the
PIB CMP PPU 030. Individuals have a right to protection of and access to their personal information stored in each corresponding PIB in accordance with the Privacy Act and the Access to Information Act.
Details on these matters are available at the Infosource website (http://infosource.gc.ca) and through the CIC Call Centre. Infosource is also available at public libraries across Canada.
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Citoyenneté et
Immigration Canada
Citizenship and
Immigration Canada
PAGE # OF ##
PROTECTED WHEN COMPLETED -
B
IMM 5257 (02-2015)
Schedule 1
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)
Validate
click to sign
signature
click to edit
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