Citizenship and

Immigration Canada

Fillable Form

Citoyennet et
Immigration Canada

PROTECTED WHEN COMPLETED - B

PAGE 1 OF 4

APPLICATION FOR A PERMANENT RESIDENT CARD

1. Language you prefer for correspondence:

Confused by a question? See step 2 of the instruction guide.

French

English

TYPE or PRINT in black or blue ink

2.

Date you became a permanent resident

of Canada
Year
Month
Day
2005
6
3

NOTE:

3.

You are applying to (check one box):

Obtain your first
Permanent Resident Card

Replace a lost, stolen, destroyed or never

received Permanent Resident Card

Renew your present

Permanent Resident Card

If you are applying to renew your present card and

a) your card has expired, you should return it with this application;
b) your card is still valid you may hold on to it and return it to the Citizenship and Immigration Canada officer when you pick-up your new card
at a local CIC office.
If you are applying to replace your damaged card, you should return your card with this application.

A.

PERSONAL DETAILS

4.

Your full name as shown on your Record of Landing (IMM 1000) or

Confirmation of Permanent Residence (IMM 5292).

170 cm

11. Your height

Family name
(Surname)

12. Your current

residential
address in
Canada

EFTIME

or

ft

in

82 BRIGHTSVIEW DRIVE
RICHMOND HILL

Given name(s) MIHAELA

CARMEN
5.

Family name
(Surname)

13. Your mailing

address in
Canada
(if different
from above)

N/A

Given name(s)

6.

Your sex

7.

Your date of birth

8.

Your country
ROMANIA
of birth

9.

Your country
ROMANIA
of citizenship

Male
Year

10

Postal Code

Day

12

14. Your telephone numbers

Area code

10. Colour of
your eyes

Blue

Grey

Brown

Green

Black

Hazel (yellowish brown)

Other

B.

L4E 3Z1

N/A

Female
Month

1974

Postal Code

ONTARIO

Your current name, if different from above

(Note: you must provide supporting documents for any change in your
name. Consult the Document Checklist (IMM 5574))

At home

Alternative

905

Number

773-5031

)
)

15. Your current marital status

Never married
Legally separated

Married

Widowed

Divorced

Common-law

YOUR IMMIGRATION HISTORY

18. Has an Immigration Officer ever issued you a Report Under
Subsection 44(1) or made the decision that you have not met
the residency obligations required of Canadian permanent
residents?

16. Place you became a permanent resident of Canada

City

TORONTO

Province

ONTARIO

Yes

No

17. Have you ever been issued a removal order in Canada?

Yes

C.

No

ADDRESS, WORK AND EDUCATIONAL HISTORY FOR THE PAST FIVE YEARS

19. Your address history for the past 5 years or if you became a permanent resident less than five years ago, your address history since becoming a
permanent resident
From
Y
M

To

Street and number

2005

2005

110 BRIGHTSVIEW DRIVE

2005

2008

4190 BATHURST STREET, SUITE 208

2008

82 BRIGHTSVIEW DRIVE

City or town

Province

Country

RICHMOND HILL

ON

CANADA

TORONTO

ON

CANADA

RICHMOND HILL

ON

CANADA

This form is made available by Citizenship and Immigration Canada and is not to be sold to applicants.
IMM 5444 (01-2010) E

(DISPONIBLE EN FRANAIS - IMM 5444 F)

PAGE 2 OF 4
C.

ADDRESS, WORK AND EDUCATIONAL HISTORY FOR THE PAST FIVE YEARS (continued)

20. Your work and/or educational history for the past 5 years or if you became a permanent resident less than five years ago, your work and/or educational
history since becoming a permanent resident. If you have not worked or studied, write N/A (not applicable).
From

To

2005

2005

2006

2006

2007

Name of employer or name of educational institution

attended (do not use abbreviations)

City or town

Province

Country

12 CO-UP TOWING SERVICES LTD.

TORONTO

ONTARIO

CANADA

12 SENECA COLLEGE

TORONTO

ONTARIO

CANADA

DAVIS-REA LTD.

TORONTO

ONTARIO

CANADA

21. Have you travelled or lived outside of Canada in the last five years (or if you became a permanent resident less than five years ago, since becoming a
permanent resident)?

No
From
Y
M

To
Y

Yes

List all your absences:

Your location during your absence (city, country)

Reason for absence

Number of days

2006

2006

SANTA LUCIA, CUBA

VACATION

2007

2007

TURDA, ROMANIA

VACATION

2009

2009

TURDA, ROMANIA

VACATION

28

Total number of days

42

If your total equals 1095 days or more, you must complete Section D.
D.

RESIDENCY OBLIGATION
Complete this section if you have been outside of Canada for 1095 days or more in the past five years.

22. If you have been outside of Canada for 1095 days or more, list your absences from Canada in the past five years in the following situations, if applicable.
If you became a permanent resident less than five years ago: list absences from the time you became a permanent resident to present.
Option 1 - Absence while accompanying a family member who is a Canadian citizen
Name of family member

Provide proof of Canadian citizenship.

Relationship to you

Provide proof of your relationship.

From
Y
M

To

Your address during your absence

Number of days

Total number of days

Option 2 - Absence while employed by a Canadian business or in the Canadian federal or provincial public service
Provide proof of full-time Canadian employment
From
Y
M

To

Your address during your absence

Number of days

Total number of days

IMM 5444 (01-2010) E

PAGE 3 OF 4
D.

RESIDENCY OBLIGATION (continued)

Option 3 - Absence while accompanying a family member who is a permanent resident of Canada and who is employed by a Canadian business or in
the Canadian federal or provincial public service
Name of family member

Provide proof of this person's permanent resident status and

proof of this person's full-time employment.

Relationship to you

Provide proof of your relationship.

From
Y
M

To

Your address during your absence

Number of days

Total number of days

E.

DECLARATION OF APPLICANT

23. This declaration covers the information that I have provided on this form and all the information submitted in my application for a Permanent Resident
Card as well as in the attached accompanying documents.
z

I declare that the information I have given is truthful, complete and correct.

I understand that any false statements or concealment of a material fact may be grounds for my prosecution or removal.

The photographs enclosed are a true likeness of me.

I am a permanent resident of Canada.

I am not a Canadian citizen.

I understand all the foregoing statements, having asked for and obtained an explanation on every point that was not clear to me.

I realize that once this document has been completed and signed, it will form part of my Immigration Record and will be used to verify my family details on
future applications.

I will immediately inform Citizenship and Immigration Canada if any of the information or the answers provided in my application forms change.

Signature
of declarant
Year

Date

2010

Month

City

RICHMOND HILL

Province

ONTARIO

Day

11

Signature of parent
or guardian, if applicable
Date
I am the applicant's:
(check appropriate box)

IMM 5444 (01-2010) E

Year

Mother

Month

Day

Father

Guardian

PAGE 4 OF 4
F.

SOLEMN DECLARATION CONCERNING A LOST, STOLEN, DESTROYED OR NEVER RECEIVED PERMANENT RESIDENT CARD

24. Complete this section only if you are applying to replace a lost, stolen, destroyed or never received PR Card.

Permanent Resident Card number

Year

Month

Day

Year

Month

Day

Date of issue

My Permanent Resident Card was

Lost

Stolen

Destroyed

Never received

on or about

at

Under the following circumstances (full information must be provided below):

I have made the following efforts to locate this document

(if applicable, indicate police authorities notified and attach a copy of police report or incident report number):

Should I ever regain possession of my original PR Card, I promise to return it immediately to a Citizenship and Immigration Centre, or, if I am outside Canada, to the
nearest Canadian Embassy, Consulate or High Commission.
I solemnly declare that the information I have provided is true, that is of the same force and effect as if made under oath, and that it was freely given. I authorize the
department of Citizenship and Immigration Canada to verify the information I have provided. I also understand that the provision of any false or misleading
information may lead to prosecution in accordance with Section 127 of the Immigration and Refugee Protection Act.
Signature
of declarant
Date

Signature of parent
or guardian, if applicable
Year

Month

Day

Date

Year

Month

Day

The information you provide on this form is collected under the authority of the Immigration and Refugee Protection Act and will be used to determine whether the term
and conditions of your permanenet residency were maintained and whether you should be granted a Permanent Resident Card. It will be retained in the Personal
Information Bank CIC PPU 067 entitled Permanent Resident Card as identified in Infosource. It may be shared with other organizations in accordance with the
consistent use of information under the Privacy Act. Under 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 infosource.gc.ca and through the Citizenship and Immigration Call Centre. Infosource is also
available at Public Libraries in Canada.
IMM 5444 (01-2010) E