PROTECTED WHEN COMPLETED - B

PAGE OF

APPLICATION FOR WORK PERMIT

MADE OUTSIDE OF CANADA
If you need more space for any section, print out an additional page containing the appropriate section, complete and submit it with your application.

Validate Clear Form

1 2 OFFICE USE ONLY

UCI *I want service in
Validated

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 Have you ever used any other name (e.g. Nickname, maiden name, alias, etc.) ? *No *Yes
Family name Given name(s)

3 *Sex 4 Date of birth 5

Place of birth
*City/Town *Country

*YYYY *MM *DD

6 *Citizenship

7 Current country of residence:

Country Status Other From To
* *

YYYY-MM-DD YYYY-MM-DD
8 Previous countries of residence: During the past five years have you lived in any country other than your country of citizenship or your current *No *Yes
country of residence (indicated above) for more than six months?
Country Status Other From To

YYYY-MM-DD YYYY-MM-DD

YYYY-MM-DD YYYY-MM-DD
9 Country where applying: Same as current country of residence? *No *Yes

Country Status Other From To

YYYY-MM-DD YYYY-MM-DD
10 *a) Your current marital status Date
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
YYYY-MM-DD
c) Provide the name of your current Spouse/Common-law partner
Family name Given name(s)

FOR OFFICE USE ONLY - DO NOT WRITE IN THIS SPACE

IMM 1295 (03-2015) E This form is made available by Citizenship and Immigration Canada and is not to be sold to applicants.
APPLICATION FOR WORK PERMIT MADE OUTSIDE OF CANADA (DISPONIBLE EN FRANÇAIS - IMM 1295 F)
 PAGE OF
Applicant Name Date of Birth

PERSONAL DETAILS (CONTINUED)

11 Have you previously been married or in a common-law relationship? *No *Yes
Provide the following details for your previous Spouse/Common-law Partner:
Family name Given name(s)

c) Date of birth Type of relationship From To

YYYY MM DD YYYY-MM-DD YYYY-MM-DD

LANGUAGE(S)
1 *a) Native language/Mother Tongue b) If your native language is not English or French, which *c) Are you able to communicate in English and/or French?
language do you use most frequently?

d) Have you taken a test from a designated testing agency to assess your proficiency in English or French? *No *Yes

PASSPORT
1 *Passport number 2 *Country of issue 3 *Issue date 4 *Expiry date

YYYY-MM-DD YYYY-MM-DD

CONTACT INFORMATION

If submitting your application by mail:

- 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 e-mail and mailing address(es) in this section and on the IMM5476 form.

1 Current mailing address

P.O. box Apt/Unit Street no. *Street name

*City/Town *Country Province/State Postal code District

2 Residential address Same as mailing address? *No *Yes

Apt/Unit Street no. Street name City/Town

Country Province/State Postal code District

3 Telephone no. Canada/US Other 4 Alternate Telephone no. Canada/US Other

Type Country Code No. Ext. Type Country Code No. Ext.

5 Fax no. 6 E-mail address

Canada/US Country Code No. Ext.

Other

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)

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)

b) Complete Address of Employer (Canadian or Foreign):

CITIZENSHIP AND IMMIGRATION CANADA

IMM 1295 (03-2015) E CITOYENNETÉ ET IMMIGRATION CANADA
APPLICATION FOR WORK PERMIT MADE OUTSIDE OF CANADA
 PAGE OF
Applicant Name Date of Birth

DETAILS OF INTENDED WORK IN CANADA (CONTINUED)

3 Intended location of employment in Canada?
Province City/Town Address

4 My occupation in Canada will be:

*Job title *Brief description of duties

5 *From *To 6 Labour Market Impact Assessment (LMIA) No.

Duration of expected
employment
YYYY-MM-DD YYYY-MM-DD

LIVE-IN CAREGIVER PROGRAM

1 Type of care, indicate all that apply: 2 No. of persons requiring care

Child care Disabled Elderly Other

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

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

From Field and level of study School/Facility name

YYYY MM
1 To City/Town Country Province/State

YYYY MM

EMPLOYMENT
Give details of your employment for the past 10 years, including if you have held any government positions (such as civil servant, judge, police officer, mayor, member of parliament,
hospital administrator.)
From *Current Activity/Occupation *Company/Employer/Facility name

*YYYY *MM
1 To *City/Town *Country Province/State

YYYY MM
From Previous Activity/Occupation Company/Employer/Facility name

YYYY MM
2 To City/Town Country Province/State

YYYY MM
From Previous Activity/Occupation Company/Employer/Facility name

YYYY MM
3 To City/Town Country Province/State

YYYY MM

BACKGROUND INFORMATION
Clear Section
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).

CITIZENSHIP AND IMMIGRATION CANADA

IMM 1295 (03-2015) E CITOYENNETÉ ET IMMIGRATION CANADA
APPLICATION FOR WORK PERMIT MADE OUTSIDE OF CANADA
 PAGE OF
Applicant Name Date of Birth

BACKGROUND INFORMATION (CONTINUED)

2
a) Have you ever remained beyond the validity of your status, attended school without authorization or worked without authorization in Canada? No Yes

b) Have you ever been refused a visa or permit, denied entry or ordered to leave Canada or any other country? No Yes

c) Have you previously applied to enter or remain in Canada? No Yes

d) If you answered “yes” to question 2a), 2b), or 2C please provide details.

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

b) If you answered “yes” to question 3a) above, please provide details.

4 a) 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)? No Yes

b) If you answered yes to question 4a), please provide dates of service and countries where you served.

5 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? No Yes

6 Have you ever witnessed or participated in the ill treatment of prisoners or civilians, looting or desecration of religious buildings? No Yes

If you answered “yes” to any of questions 3 to 6 above, or upon request of a visa officer, you MAY BE REQUIRED to fill out IMM 5257 Schedule 1.

SIGNATURE
Citizenship and Immigration Canada (CIC), or an organization at CIC’ request, may want to contact you in the future to ask you about any services you received from CIC prior to the application
process (such as participation in an information forum), during the application process (including the application process itself as well as orientation or accreditation services), and services
received after arriving in Canada (including settlement, integration and citizenship). CIC will use this information, along with the information provided by other individuals, for research,
performance measurement or evaluation purposes. CIC will not use this information to make any decisions about you personally.

Do you consent to be contacted by CIC, or an organization at CIC’s request, in the future? (Y/N) No Yes

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. Date: YYYY-MM-DD
IMPORTANT NOTE:
This application must be signed and dated before it is submitted by mail.
Do not forget to include photos, fees (if applicable) and any other documents required. Review the application guide for more information and verify that you have completed
and provided all of the required documents as per the document checklist.
DISCLOSURE
The information you provide to CIC is collected under the authority of IRPA to determine if you may be admitted to Canada as a worker. 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 054). 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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CITIZENSHIP AND IMMIGRATION CANADA
IMM 1295 (03-2015) E CITOYENNETÉ ET IMMIGRATION CANADA
APPLICATION FOR WORK PERMIT MADE OUTSIDE OF CANADA