Citizenship

Dear customer, by filling out this form we will be able to carry out your process efficiently, this information will be used exclusively for your application. It is necessary that you answer all questions honestly and completely, as this is information reviewed by the Government of Canada. If the question does not apply to your process, please write “N/A”.

Personal Information

Family name (Last name)*

Given name(s) (First name) *

Have you changed your name since becoming a permanent resident?*

Name used

Have you ever used any other name?*

Family name (Last name)

Given name(s) (First name)

Why was this name used?

Personal Information II

Email*

Which language do you speak?*

Do you have special needs requiring accommodation?*

Unique client identifier (UCI)*

Gender*

Do you need to change your gender designation for your citizenship application?*

Height*

Eye colour*

Marital status*

Date of birth*

Have you corrected your date of birth on your immigration documents or legally changed it since coming to Canada?*

Do you need to correct your date of birth for your citizenship application?*

Contact Information

Home address (Country or territory)

City or town*

Province*

Postal code*

Street name*

Street number*

Apt or unit

mailing address same as home address?

Is this phone number from Canada, United States or other?*

Type of phone number*

Do you have another (alternative) phone number?*

Alternative phone number

Do you have proof of knowledge of Englis or French?*

Which proof of language you will submit?

Identification

Choose the ID you want to provide*

The second ID can be issued by the Canadian or a foreign government*

List all addresses inside and outside of Canada during your entire 5-year eligibility period

1.- From*___________________

To*

Country or territory*

Address*

2.- From*___________________

To*

Country or territory*

Address*

3.- From*___________________

To*

Country or territory*

Address*

Identification II

If the question does not apply to your process, please write “N/A”

4.- From*___________________

To*

Country or territory*

Address*

5.- From*___________________

To*

Country or territory*

Address*

6.- From*___________________

To*

Country or territory*

Address*

Identification III

EMPLOYMENT
Include any periods of unemployment retirement working as a homemaker self-employment
Enter details of all your employment and education history in the past 5 years (your eligibility period)

1.- From*___________________

To*

Occupation or activity*

Employer or institution*

Country or territory*

2.- From*___________________

To*

Occupation or activity*

Employer or institution*

Country or territory*

3.- From*___________________

To*

Occupation or activity*

Employer or institution*

Country or territory*

Identification IV

If the question does not apply to your process, please write “N/A”

4.- From*___________________

To*

Occupation or activity*

Employer or institution*

Country or territory*

5.- From*___________________

To*

Occupation or activity*

Employer or institution*

Country or territory*

6.- From*___________________

To*

Occupation or activity*

Employer or institution*

Country or territory*

Prohibitions

Are you now serving a term of imprisonment?*

Are you now on probation?*

Are you now on parole?*

Are you now serving a sentence outside Canada for an offence?*

Are you now charged with, on trial for, subject to or a party to an appeal relating to an offence under the Citizenship Act or an indictable offence in Canada?*

Are you now charged with, on trial for, subject to or a party to an appeal relating to an offence outside Canada?*

Are you now, or have you ever been, under a removal order (have you been asked by Canadian officials to leave Canada)?*

Are you now under investigation for, charged with, on trial for, subject to or a party to an appeal relating to, or have you been convicted of a war crime or a crime against humanity?*

Prohibitions II

In the 5 years immediately before the date of your citizenship application, were you prohibited from being granted citizenship or taking the Oath of Citizenship because of misrepresentation or withholding material circumstances?*

In the 10 years immediately before the date of your citizenship application, was your Canadian citizenship taken away (revoked) for reasons of false representation, fraud, or knowingly concealing material circumstances?

In the 4 years immediately before the date of your citizenship application, have you been convicted of an indictable offence under any Act of Parliament or an offence under the Citizenship Act?*

Prohibitions III

In the 4 years immediately before the date of your citizenship application, have you been convicted of an offence outside Canada, regardless of whether you were pardoned or otherwise granted amnesty for the offence?*

While a permanent resident, have you been convicted in Canada of terrorism, high treason, treason, or spying offences?*

While a permanent resident, have you been convicted outside Canada of terrorism?*

While a permanent resident, have you been served as a member of an armed force of a country or territory or an organized armed group and that country or territory or group engaged in armed conflict with Canada?*

Physical Presence

During your 5-year eligibility period, did you live outside of Canada as a Crown servant?*

During your 5-year eligibility period, did you live outside of Canada as a family member of a Crown servant? *

Date you became a permanent resident*

Consent

I authorize IRCC to forward my personal information to my Member of Parliament.*

I authorize IRCC to give my information to Elections Canada*

Choose the type of citizenship certificate you want to receive*

I declare that I have answered all the questions in this application completely and truthfully
I certify that the information contained in this document is complete, accurate and objective. I also realize that once this document has been completed and signed, it will become part of my immigration record and will be used to verify my family details in future applications
I agree that Rita Khalfon Immigration Consulting may use my data to carry out my immigration process

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