CANADA TERRORIST ALERT FORM

*Please Print Clearly and if some of these categories don't apply to you then please state by writing N/A* Name (Mr. Mrs. Miss.) Nationality Type of Religious: Religious belief: Have you ever leave in any of the south or Northern America States Before Yes No If yes then where and what was your job? Have you been convicted of any crime in any Country Yes No In period of either peace or war, have you been involve in the commission of a war crime or crime against humanity Yes Person to contact in Case of Emergency Address: Name Occupation Relationship No Permanent Resident Address:

Phone Number

Fax Number

Postal Address

Religious Leaders/Address What Languages do you speak? (In order of fluency): Passport Number: Passport: Marital Status (Tick one): Single Married Divorced Name and address of Applicant / Organization: Social Security Number: (SSN) Return these forms along with your Two Passport Photograph and refundable fees of $ 3000USD per applicant. OFFICIAL REMARK
NUMBER OF APPLICANTS: .. ...

Type of

DEPARTMENTAL OFFICER . MEMBERSHIP NUMBER GROUP REGISTRATION NUMBER .

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