lmrrigtation. Refugees Immigration.

R6fugies PROTECTED WHEN COMPLETED - B

and Citiza IShip C8nada et Citoyennet~ canada
Page 1 of4

FOR CIC USE ONLY

SCHEDULE A Client IO/UCI/FOSS 10
BACKGROUND/ DECLARATION
Before you start complebng this fonn. 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

If there Is not enougti space to pro~ide au the necessary information. attach to th)S fonn ·a separate sheet of paper with further details. Print your name at the lop of eacil add1t10nal
sheet and indicate the form's title and the number of the question you are answering.

BEFORE YOU START. READ THE INSTRUCTION GUIDc

TYPE or PRINT In black Ink

Indicate whetti.r you are

D The pnncipal apphcant [Z] The spouse, common-law partner or dependent child aged 18 years or older of the pnnc,pal applicant
1. Yolff fufl name
Fanllly name Given name(s)
. M,.,n .. r,.;,
:l1dl l qi

2. Your full name written In YOU{ native language or script 3. Your date of birth (YYYY-MM-DD)
(e g. Alablc. Cynihc. Chinese. K"orean. Japanese characters or Chinese commerc1al/te/'E!Qraph1c code)
::,7t-:L.-L7
=~

'- Personal details of your father

Fam1lyname Given name(s)
AL'1b ...,, .>I- ~,at.; z,1qul J-j ~.>-'

Date of birth (YYYY-MM-OO) Town/City of birth Country or territ~ of birth Date of death. If deceased (YYYY-MM-OO)
.. ,..,-
l:t4C-:l-C·2 fc,.:. Y"'-' A·fgl1:.-.1d::;L~n -. .,- l

5. Personal details of your mother

Family name at ·birth Given name(sJ
Arab -:'.r- B.;,.n..:,

Date of birth ('(YYY-MM-DD) Town/Crty of birth Country or lemtory of birth Date of death. 1f deceased (YYYY-MM-OO)
1~51-1. s-r,.3 f,~::yab Af.rhcinL· tan

6. 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? 0
b) been oonv1ded of. or are you aurently charged with. on tnat for. or party to a crime or offence. or subject of any cnminal proceedings In any ()(her
COl.lltry or territory? 0
c) .made previous ciaans ior refugee protecl,on in Canada or at a Canadian Visa office abroad, in any other country(res) or lerrilOfY(tes). or ~1th the
United Nations High Commissioner for Refugees (UNHCR)? D0
d) been refused refugee status. an immigrant or permanent resident V1sa (1nclud1ng a Cert1ficat de s~/ection du Quebec (CSQ) or apptication to the
Provlnaal Nominee Program) or visitor or temporary resident vrsa. to Canada or any other country or temt~? 0
e) been refused admission to. or ordered to leave, Canada or any other country or terntory? 0
Obeen involved in an act of genocide, a war crime or in the comm,ssron of a cnme against humanity? 0
g) used. planned or advocated the use of armed stru{Jgle or violence to reach poltlical. reug,ous or social objectives? 0
h) been associated with a group lhat used. uses, advocated or advocates lhe use of armed struggle or violence lo reach pohtIcal. rehgIous or socaal
objectives? 0
-
i) been member of an organization that is or was engaged m an acttv11y that Is part of a pattern of cominal activity? 0
J) been defamed. incarcerated or put in Jarl? 0
k) had any senous drsease or physical or mental disorder? 0
If your answer to any of these questions 1s YES, provide details below

This form Is mad, avaHablt by CitlZtnshlp and Immigration Canada and Is not to be sold to applle.1nts.

IMM 5669 (05-2021) E (DISPONIBLE EN FRANCAIS • IMM 5669 F) Canada

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/
Page 2 of 4
7. Educ~on
Grve the number of years of school you successfully completed for each of the following levels of education

pnmary sctiool
D Secondary/
high school conege
Q Trade school or other
post secondary school

Grve fun details of all the secondary and post secondary education (includmg university. college and apprenticeshrp tramIng) you have hcJd
....\I.; From To
. (YYYY-MM) (YYYY-MM) Name of tnstttutton City and country or territory Type of certificate or
diploma issued Field of study
'
. - ·,.- . ' 1-1:: :... I_. i\ .:1\Til:-.1\ F.aryab Af•Jh-, n.! ., i:: ,,r, Ii~_•
rc:r-Tii:T" !,TC:. .-4::-.J.;- L ti : '11

: ·I lt 1- I: ~--·•4-12 :...EA ~:ATA":-·A Fc11 yab A f,,,hnn L. i: "'', :,1 ;·:..r •MA :i i 'Jh c"
0
• I i
:• 11 '· - 1'1: : ·11 ,,_ 12 TE.~•.. nE":-· [r_,11r~.;T 1:IN :_,E[ ,1.F T F 1t y.1b Af•Jl1cH1:.:: t,,n r,EFTIFI ~ATE • - ,1 ..'.-:..-:11 · -
-
~I : •:. - I I ;:_,~1-12 PNIVE"i-:3 IT'1 rel l yt1i_1 Afgh.:1111~ t r.r1 !:_,IF::... 1MA ;-i11ri 111 l <- 11 ·.:.

8. P..-sonal history

Provide the details of your personal history smce the age of 18. or the past 10 years. whichever is most recent
Start with the most recent infom,afion. Under "Activity". write your occupalJon or ;ob trtle 1f you were wonong If you were not working. provide 1nformatron on what you v.. ere doing
(for example: unemployed. studying. travelling. retired. ,n detention. etc.) If you were outside your country or terntory of nationality. 1nd1cate your status ,n that country or terntory

Note: Plnse errsllft that you llo not le-ave any gaps. tn time.

0 Failure to account for all time periods will result in a delay m the processing of your application

From Tb City or town Starus in country Name of comS)any, employer,

·(YYYY-MM) (YYYY-MM) Activity
and country or territory or territory school. facility. as applicable
2023:.(1}. 20i3-l~ I11)-':illl •l•. y<:-i r~1~111dr:,..,,i : a~. t-: • i '.:..

20,)4-04 2021-07 T<":c~dl': l ? .1 ry,1l• Af,_1:1:111:~t.~n H: i., ~•. I : l T..:...~,_· .-.:.

~I

9. Membership of association with organtzaUons

What organizations have you supported. been a member of or been associated with? Include any pohtIcat. sooal. youth or s~nt orgarnza110n. trade unions ano proress10nal
asSOClatK>ns. Do not use abbrewmons. Indicate the c,ty and country or territory where you were a member.
Wnte "NONE" in the box if you have not been a member of any assocIat1on/orgamzat1on

From To
Nam• of organization ActivttiH andlor positions City and country
(YYYY-MM) (YYYY-MM) Type of organization
t.ld wtthin organization or tHritory

Nc.1N£

10. Government positions

L1sl any government pos1t1ons (such as civil serva,,t. Judge, pohce omce,. en,ploytiE: 11\ a ::.ecu11ty 01ganrzalloo) you ha'l/e held Include positions you hdve held befoce Of ane,
your retirement Do not use abbrev1at1ons Write "NONE" in the box 1f you have not held any govemmenl pos,ttons

Country or te"ltory and level of

From To
Jurlsdlctlon(e.g. national, regional, Department/Branch Activities and/or positions held
(YYYY-MM) (YYYY-MII)
municipal)

MJNE.

IMM 5669 (05-2021) E

 p,oy;de t,e1ow -p1ete details of miliWY and/Or paramllita,Y se,vice tor each of Ille c0unures in wi,ose armed rorce• you serVed
f 1,1111'",Y
11. Write and/0'" ,..,...llltarY
-NONE" tt,e bOJC Wyou . -not undertaken mitrtarY and/or paramititarY service- Do not ieav• anY Q8PS in tim•-
.hlJVf' r Reason tor end of
senttc• I
Dates and pr:aces

N•""' ot eoontJY o< ..,.uorY [NoNE

L-------------------__.j

I
l
&ranch -of servfce. unit numb*~ and
names of your conunandlnill officers
I fWlk(s)
I1
of anY combat 1

:
I TO
r
, - - - - r - - - - + - - - - - - - - - - _ J _ - - - - J _ T - - - - - _ L - -I - - - - _ _ J I1I
(YYYY-MM)

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F- T r ey or tt,e past 10 years. wt>r<:h••"' rs most 1
- I CVVVV-MMI o trved srnce your 18u, t,uthd
e you have recent. DoI not use P O
::J IList all addresses wher ~..- Postal code/ '
,~ zr,21 ,.,l
2,0,-nl I ,,.,~., 11, He-us• llJ cuyortown Provlnce,sta-or
District ZJpcode - --,
eountryor10ffito~l
===Ei=t~(YVYY~;~-M~M=)=~I==~~S~tr~Nt=~•n~d~
ii ~num~~be~r~~==±I
-u,,e J - • - -·' l ~- bo~x;addr;ie~ss~es~.
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IMM 5669 (05-2021) E

 -•~• tltlO J\ Of ·-· ...:vaiua.ting ••ave liveo nl-;y•
dn Qo\'e rnrne nt
aPP llca nt Your sun Posses
abllit -, au\h ont,
\ Oec \are 'hat th for adll )~I on Your beha '
. l~s of all reco rds . 0
e ,ntormat; on to. Cana o conc ernin , ... .JJ.,, -0 Page 4 of 4
and •nfor mar
°"Ih a"""
.._ tl1•"en • a or rerna inin~ ~ncy inves
\1ga tio:n any gove rnme nt _:.
IS truthful anac1a • arres ts h autho
• com plete and Purs uant to C • arges. tnai rity -
• including par . _
corre ct atlad1an le.gisla\i,,,.~· COnVictions
and tee_ JUd1cia1 and
""',. sentences This

I Sign ature

Inte rpre ter d ~ FICI AL APP OIN TED ~~ MTO'W

,. -
. You MA-Y-Bt
rauon HE. CANAD ASKED TO $
lAN GOVERNMENT IGN IN THt -
P'RtS °ENC E OF A-
·- Date (YYYY-MM-DD)
- REP ffi:SE NTATIV "t or THE C
\ ha lang uage the cont ent ANAOIAN
ve bee n '"form
dec\ arat\ Qn con sei: 1-by the of this appl icati
l>ers on conc ern do sol
nt\0t rs1y behe \'1ng it to b on and any relat ed form s
to - • emnl y declare that I have faithf
e,d. and I do \'elil y belaev
e rue and k the pers on conc erne d ul
e. \hat th
no-w ing that I\ is Of the : : ly and accurately interpre·ed
comp letely Unde rstan ds the
\ in the

-
me force and effec t a •
natur e and effec t of the
s is made unde r oath
Sole mn 'dectaratlon se forms. and I make this I
•
soem n

'· Sign ature of interp reter

appl icati on is truth ful

ma<1e und er • com plete and corre ct
oath .
• and I mak e this SOiemn decla
.
• do solem nly declare that th
ratio n cons cient iousl y belie
ving it to be tru nd
e tnformat10n I have Qrven in
e a knowing that • the foregoing
It IS of the same for
ce and effect as 1f
Dec lare d befo re me at
Sign ature of appli cant

this
day of
\
-
Can adia n gove rnme nt offic
ial Nam e lPlea se print or of the vear
type )

Signature

Pers onal m1or mat1 on prov

ided on this form 1s colle
Prot ectio n Act (\RP A). cted by lmm1gra\1on. Refu
The p&rs onal in10Jmat1on gees . and C1t1zensh1p Cana
tede ral gove rnme nt mst1 will be used for the purp ose da {IRCC) under the authonty
tut1ons for the purp ose of of pcocessing an applicatK>O of the tmm1g1a11on and Refugee
purp ose of vahd ating 1den val,d abng mformal1on and The personal mformat1on provid
t1ty. ehg1b1h\y and adm1ss1b1 ehg1b11tty The personal 1nfom ed may be disclosed to other
\he purp ose of vahd at,ng hty The perso nal inform ation ,at1on may also be disclosed
ehg1b1hty and adm1ss1b1hty. may also be disclosed to pro11 to ta,\ enforco:ment oo<11es tor the
mc1al/tern1onal governments and
fore1gn governments for
Pers onal nform at,on may
1 ·a\so be used for othe r purp
man agem ent. subs eque oses inclu ding resea rch. stat1s
nt prog ram ehg1b1hty, strat \lcs. program and pohcy evalu
egy deve lopm ent and repor aoon. mternal audit. comphance
ting program integnty r•'-k
Failu re to com plete the
1orm in full may resu lt in t b oc ssed
corre ct,on of their pers onal a delay or the apph caho n no The Pnvacy Act gives rnd1v1
com plain t \0 th e
mform at1on \f you are no\
sat1sf1ed with the mann er m
emg pr helRCC h dies our personal informdua!s the nght of access to protection
ation. you may exercise 3nd
Pers onal \ntor mat, on Bank . • The collectton. use. wdh1cl
1scos ndanretent~on of your personal your right to ftle a
- \RCC PPU 009. 013. 039. ure a mtorm allon ,s further desc11bed '" IRCL"

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042 's

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IMM 5669 l05-2 021) E