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YYYY-MM-DD
Name of city or port of entry AND Province
Full name as shown on your Record of Landing (IMM 1000), Confirmation of Permanent Residence (IMM 5292 or IMM 5688) or last PR card
Full name as shown on your Record of Landing (IMM 1000), Confirmation of Permanent Residence (IMM 5292 or IMM 5688) or last PR card
Full name as shown on your Record of Landing (IMM 1000), Confirmation of Permanent Residence (IMM 5292 or IMM 5688) or last PR card
if different from the above. This is the name that will appear on your PR card or PRTD. (if applicable) NOTE: You must provide supporting documents for any change in your name. Consult “Legal Name Change”
YYYY-MM-DD
Primary Telephone number
Primary Telephone Number
Primary Telephone Number
Primary Telephone Number
Format: 1. From (YYYY-MM-DD) To (YYYY-MM-DD) - Apartment, street no. and street name - City or town - Province/District/State - Country or territories. 2. From (YYYY-MM-DD) To (YYYY-MM-DD) - Apartment, street no. and street name - City or town - Province/District/State - Country or territories. PLEASE LIST ALL ADDRESSES FROM THE LAST 5 YEARS AND DO NOT LEAVE ANY GAPS
Format: 1. From (YYYY-MM-DD) To (YYYY-MM-DD) - Name of employer or educational institution or organization (do not use abbreviations) - Activity - City or town - Province/District/State - Country or territories 2. From (YYYY-MM-DD) To (YYYY-MM-DD) - Name of employer or educational institution or organization (do not use abbreviations) - Activity - City or town - Province/District/State - Country or territories . PLEASE LIST ALL ACTIVITIES FROM THE LAST 5 YEARS AND DO NOT LEAVE ANY GAPS
Format: 1. From (YYYY-MM-DD) To (YYYY-MM-DD) - Your location(s) during your absence (city, country/territory) - Reason for Absence - If “Other” Please add reason - Days 2. From (YYYY-MM-DD) To (YYYY-MM-DD) - Your location(s) during your absence (city, country/territory) - Reason for Absence - If “Other” Please add reason - Days. PLEASE LIST ALL TRAVELS FROM THE LAST 5 YEARS AND DO NOT LEAVE ANY GAPS
By selecting "Yes" in the box below, and by signing this form, I hereby give my consent to the Canada Border Services Agency (CBSA) to disclose the details of my history of entries into Canada to Immigration, Refugees and Citizenship Canada (IRCC) in order to assist IRCC in determining my eligibility for a PR card or a PRTD. I also hereby authorize IRCC to collect the history of my entries into Canada from the CBSA and to collect my social insurance number for the purpose of requesting that the Canada Revenue Agency (CRA) disclose my income tax information and residency information for any taxation years required to assist in determining whether I meet the residency obligation as set out in section 28 of the Immigration and Refugee Protection Act. Consent to disclose my history of entries into Canada (CBSA)