PROTECTED WHEN COMPLETED - B

IMM **** (**-****) E

This form is made available by Citizenship and Immigration Canada and is not to be sold to applicants.

(DISPONIBLE EN FRANÇAIS - IMM 1295 F)

PAGE 1 OF 4

APPLICATION FOR WORK PERMIT

MADE OUTSIDE OF CANADA

UCI/Client ID 2 I want service in

PERSONAL DETAILS

1 Full name

Family name (as shown on your passport or travel document) Given name(s) (as shown on your passport or travel document) 2

Nickname/Alias

Family name Given name(s)

Have you ever used any other name? No Yes

3 Sex Date of birth

YYYY MM DD

Place of birth

City/Town Country

6 Citizenship

Current country of residence:

Country Status Other From To

Previous countries of residence: During the past five years have you lived in any country other than your country of citizenship or your current country of residence (indicated above) for more than six months? No Yes

Country Status Other From To

Country where applying: No Yes

Country Status Other From To

Same as current country of residence?

YYYY-MM-DD YYYY-MM-DD

YYYY-MM-DD YYYY-MM-DD

YYYY-MM-DD YYYY-MM-DD

YYYY-MM-DD YYYY-MM-DD

4 5

7

8

9

Validated

1 OFFICE USE ONLY

FOR OFFICE USE ONLY - DO NOT WRITE IN THIS SPACE

b) (If you are married or in a common-law relationship) Provide the date on which you were married or entered into the common-law relationship 10 a) Your current marital status Date

Family name Given name(s)

c) Provide the name of your current Spouse/Common-law partner YYYY-MM-DD

00 00

IMM 1295 (01-2011) E

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Applicant Name Date of Birth

PERSONAL DETAILS (CONTINUED)

Have you previously been married or in a common-law relationship? No Yes Family name Given name(s)

Type of relationship From To

YYYY-MM-DD

Provide the following details for your previous Spouse/Common-law Partner: 11

YYYY-MM-DD

LANGUAGE(S)

1 a) Native language b) If your native language is not English or French, which language do you use most frequently? PASSPORT

YYYY-MM-DD YYYY-MM-DD

1 Passport number 2 Country of issue 3 Issue date 4 Expiry date CONTACT INFORMATION

Residential address

Current mailing address

- All correspondence will go to this address unless you indicate your e-mail address below.

- Indicating an e-mail address will authorize all correspondence, including file and personal information, to be sent to the e-mail address you specify.

- If you wish to authorize the release of information from your application to a representative, indicate their address below and on the IMM5476 form. P.O. box Apt/Unit Street no. Street name

City/Town Country Province/State Postal code District Same as mailing address? No Yes

Apt/Unit Street no. Street name City/Town

Country Province/State Postal code District

Telephone no.

Type

3 Canada/US Other

Country Code No. Ext.

Alternate Telephone no.

Type

4 Canada/US Other

Country Code No. Ext.

Fax no.

Canada/US

Other

Country Code No. Ext.

5 6 E-mail address

1

2

DETAILS OF INTENDED WORK IN CANADA

1 What type of work permit are you applying for?

2 Details of my prospective employer (attach original offer of employment) b) Complete Address of Employer (Canadian or Foreign): a) Name of Employer (If you are employed by a foreign employer who has been awarded a contract to provide services to a Canadian entity, please identify the foreign employer here) 3 Intended location of employment in Canada?

Province City/Town Address

IMM 1295 (01-2011) E

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Applicant Name Date of Birth

Job title

4

Brief description of duties

My occupation in Canada will be:

6

YYYY-MM-DD

Duration of expected

employment

From To

YYYY-MM-DD

5 Labour market opinion (LMO) No.

DETAILS OF INTENDED WORK IN CANADA (CONTINUED)

LIVE-IN CAREGIVER PROGRAM

1 Type of care, indicate all that apply:

Child care Disabled Elderly Other

2 No. of persons requiring care

Have you had any post secondary education (including university, college or apprenticeship training)? No Yes YYYY MM

YYYY MM

From

To

Field of study School/Facility name

1 City/Town Country Province/State

EDUCATION

If you answered ‘‘yes’’, give full details of your highest level of post secondary education. EMPLOYMENT

Give details of your employment for the past 10 years. If retired, not working, or studying, please indicate. If you are retired, provide the 10 years before your retirement. BACKGROUND INFORMATION

YYYY MM

YYYY MM

From

To

Current Activity/Occupation Company/Employer/Facility name 1 City/Town Country Province/State

YYYY MM

YYYY MM

From

To

Previous Activity/Occupation Company/Employer/Facility name 2 City/Town Country Province/State

YYYY MM

YYYY MM

From

To

Previous Activity/Occupation Company/Employer/Facility name 3 City/Town Country Province/State

You must complete this section if you are 18 years of age or older. 1

a) Within the past two years, have you or a family member ever had tuberculosis of the lungs or been in close contact with a person with tuberculosis? No Yes b) Do you have any physical or mental disorder that would require social and/or health services, other than medication, during a stay in Canada? No Yes c) If you answered "yes" to question 1a) or 1b), please provide details and the name of the family member (if applicable). 00

00

00

00

00

00

00

00

IMM 1295 (01-2011) E

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Applicant Name Date of Birth

BACKGROUND INFORMATION (CONTINUED)

No Yes

No Yes

c) Have you ever been refused admission or been ordered to leave Canada or any other country? No Yes d) If you answered "yes" to question 2a), 2b), or 2c) please provide details. b) Have you ever been refused any kind of visa to travel to Canada? 2 a) Have you ever previously applied for any Canadian visas (For example: Permanent Resident, Temporary Resident (Visitor, Student, Worker), Temporary Resident Permit)?

3 Have you ever committed, been arrested for or been charged with any criminal offence in any country? No Yes 4

a) Have you ever been in a military, militia or civil defence unit or the police? No Yes b) If you answered “yes” to question 4a), please provide dates of service and countries where you served. No Yes

5 Have you ever been employed by a government in a security-related capacity? No Yes

6 Have you ever held a position of authority in any government, or judiciary or a political party? No Yes

7 Have you ever in periods of either peace or war, been involved in the commission of a war crime or crime against humanity, such as: willful killing, torture, attacks upon, enslavement, starvation or other inhumane acts committed against civilians or prisoners of war, or deportation of civilians? If you answered “yes” to any of questions 3 to 7 above, or upon request of a visa officer, you MAY BE REQUIRED to fill out IMM 5257 Schedule 1. The information you provide on this form is collected under the authority of the Immigration and Refugee Protection Act to determine if you may be admitted to Canada as a worker. It will be stored in Personal Information Bank CIC PPU 054, Temporary Worker Records and Case File. The information may be shared with other organizations such as the Canada Border Services Agency (CBSA), the Royal Canadian Mounted Police (RCMP), the Canadian Security Intelligence Service (CSIS) and foreign governments in accordance with the subsection 8(2) of the Privacy Act. In accordance with the Privacy Act and the Access to Information Act individuals have a 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 through the Citizenship and Immigration Canada Call Centre. Infosource is also available at public libraries across Canada.

I consent to the release to Citizenship and Immigration Canada (CIC) and Canada Border Services Agency (CBSA) of all records and information for the purpose of processing my request that any government authority, including police, judicial and state authorities in all countries in which I have lived may possess about me. This information will be used to evaluate my suitability for admission to Canada or to remain in Canada pursuant to Canadian legislation. I declare that I have answered all questions in this application fully and truthfully. Signature of Applicant or Parent/Legal Guardian’s for a person under 18 years of age. IMPORTANT NOTE:

This application must be signed and dated before it is submitted. Do not forget to include: photos, fees (if applicable), and any other documents required by the visa office. Date: YYYY-MM-DD

Contact this candidate