Citizenship and

Immigration Canada

Citoyennet et
Immigration Canada

PROTECTED WHEN COMPLETED - B

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SCHEDULE A
BACKGROUND / DECLARATION
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 permanent residence must complete
their own copy of this form.

If there is not enough space to provide all the necessary information,

attach to this form a separate sheet of paper with further details. Print
your name at the top of each additional sheet and indicate the form's
title and the number of the question you are answering.

Before you start completing this form, make enough photocopies for your needs. You can also print all or part of this form from our Web site at
www.cic.gc.ca.
BEFORE YOU START, READ THE INSTRUCTION GUIDE
TYPE or PRINT in black ink
Indicate whether you are
The spouse, common-law partner or dependent child aged 18 years or older of the principal applicant

The principal applicant

1.

Your full name

6.

Family name
Given name(s)

Have you, or, if you are the principal applicant, any of your family
members listed in your application for permanent residence in
Canada, ever:
YES
NO
a) been convicted of a crime or offence in Canada for
which a pardon has not been granted under the
Criminal Records Act of Canada?

2.

Your full name written in your native language or script

(e.g., Arabic, Cyrillic, Chinese, Korean, Japanese characters or
Chinese commercial/telegraphic code)

Year

3.

Your date of birth

4.

Personal details of your father

Month

Day

b) been convicted of, or are you currently charged with,

on trial for, or party to a crime or offence, or subject
of any criminal proceedings in any other country?
c) made previous claims for refugee protection in Canada
or at a Canadian visa office abroad, in any other country
or countries, or with the United Nations High
Commissioner for Refugees (UNHCR)?
d) been refused refugee status, an immigrant or
permanent resident visa (including a Certificat de
slection du Qubec (CSQ) or application to the
Provincial Nominee Program) or visitor or temporary
resident visa, to Canada or any other country?

Family name
Given name(s)

e) been refused admission to, or ordered to leave, Canada

or any other country?
f) been involved in an act of genocide, a war crime or in
the commission of a crime against humanity?
Year

Month

Day

Date of birth

g) used, planned or advocated the use of armed struggle

or violence to reach political, religious or social
objectives?

Town/City
of birth

h) been associated with a group that used, uses,

advocated or advocates the use of armed struggle or
violence to reach political, religious or social objectives?

Country
of birth
Date of death,
if deceased

Year

Month

Day

i) been member of an organization that is or was engaged

in an activity that is part of a pattern of criminal activity?
j) been detained, incarcerated or put in jail?

5.

Personal details of your mother

k) had any serious disease or physical or mental disorder?

Family name
at birth
Given name(s)

Date of birth

If your answer to any of these questions is YES, provide details below.

Year

Month

Day

Year

Month

Day

Town/City
of birth
Country
of birth
Date of death,
if deceased

This form is made available by Citizenship and Immigration Canada and is not to be sold to applicants.
IMM 5669 (07-2011) E

(DISPONIBLE EN FRANAIS - IMM 5669 F)

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7.

Education
Give the number of years of school you successfully completed for each of the following levels of education.
Elementary/
primary school

Secondary/
high school

University/
college

Trade school or other

post secondary school

Give full details of all the secondary and post secondary education (including university, college and apprenticeship training) you have had.
From
To
Type of certificate or
Name of institution
City and country
diploma issued
Y
M
Y
M

8.

Personal history
Provide the details of your personal history since the age of 18, or the past 10 years, whichever comes first.
Start with the most recent information. Under "Activity", write your occupation or job title if you were working. If you were not working, provide information on what
you were doing (for example: unemployed, studying, travelling, retired, in detention, etc.).
Note: Please ensure that you do not leave any gaps in time.
Failure to account for all time periods will result in a delay in the processing of your application.
To

From
Y

9.

Activity

City or town
and country

Name of company, employer,

school, facility, as applicable

Membership or association with organizations

What organizations have you supported, been a member of or been associated with? Include any political, social, youth or student organization, trade unions and
professional associations. Do not use abbreviations. Indicate the city and country where you were a member.
Write "NONE" in the box if you have not been a member of any association/organization.
From
Y

To
M

Name of organization

Type of organization

Activities and/or positions held

within organization

City and country

10. Government positions

List any government positions (such as civil servant, judge, police officer) you have held. Do not use abbreviations.
Write "NONE" in the box if you have not held any government position.
From
Y

IMM 5669 (07-2011) E

To
M

Country and level of jurisdiction

(e.g. national, regional, municipal)

Department/Branch

Activities and/or positions held

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11. Military service
Provide below details of military service for each of the countries in whose armed forces you served.
Write "NONE" in the box if you have not undertaken military service.
Name of country

From
Y

To
M

Branch of service, unit numbers and

names of your commanding officers

Rank(s)

Dates and places of any active combat

Branch of service, unit numbers and

names of your commanding officers

Rank(s)

Dates and places of any active combat

Name of country

From
Y

To
M

12. Addresses
List all addresses where you have lived since your 18th birthday. Do not use P.O. box addresses.
From
Y

IMM 5669 (07-2011) E

To
M

Street and number

City or town

Province, State or
District

Country

PAGE 4 OF 4

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
legislation.

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

Signature

Year

Date

Month

Day

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.
Solemn declaration

Interpreter declaration

I,
, 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.

I,
, 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
under oath.

Signature of
applicant

Signature of
interpreter

Declared
before me at
Canadian
Government
official

this

Name

day of

of the year

Signature
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.

IMM 5669 (07-2011) E