Formulario Embajada Canada

Citizenship and
Immigration Canada

Citoyenneté et
Immigration Canada

PROTECTED WHEN COMPLETED - B
PAGE 1 OF 2

FAMILY INFORMATION
Type of application:

Visitor

Worker

StudentOther

Complete ALL names in English and in your native language (for example, Arabic, Cyrillic, Chinese, Chinese commercial/telegraphic code, Korean, or Japanese
characters). Include ALL familymembers even if they are not accompanying you. If you need more space for any section, print out an additional page containing
the appropriate section, complete and submit it with your application.BEFORE YOU START, READ THE INSTRUCTION GUIDE, TYPE OR PRINT IN BLACK INK.
SECTION A
Date of birth
Present address
W ill
(If deceased give city and date)
accompany
Relationship
M
D
Y
Full nameMarital status
you to Canada?
SEE NOTE 1
Country
Present occupation
YES
NO
of birth

APPLICANT

SPOUSE OR
COMMON-LAW
PARTNER

MOTHER

FATHER

NOTE 1: If no spouse or common-lawpartner is listed in Section A, read and sign below.
Year

I certify that I do not have a spouse or a common-law partner.
SECTION B

Signature:

Month

Day

Date:

CHILDREN (Include ALLsons and daughters, including ALL adopted and step-children, regardless of age or place of residence)
Date of birth
Present address
Will
(If deceased give city and date)
accompany
Relationship
MD
Y
Full name
Marital status
you to Canada?
SEE NOTE 2
Country
Present occupation
of birth
YES
NO

NOTE 2: If no children are listed in Section B, read and sign below.
Year

I certifythat I do not have any children, either natural or adopted.

IMM 5645 (09-2010) E

Signature:

(DISPONIBLE EN FRANÇAIS - IMM 5645 F)

Date:

Month

Day

PAGE 2 OF 2

SECTION CBROTHERS AND SISTERS (Include ALL brothers and sisters, ALL half-brother and sister and stepbrother and sister.)
Date of birth
Present address
Full name

Relationship

Y

M

D

Country
of...