Become A Canadian

1136 Centre Street

Unit 3, Suite 469
Thornhill, Ontario L4J 3M8
CANADA
Telephone: +1-289-312-1267
Email: csr@becomeacanadian.org

Immigration Candidate Information

INSTRUCTIONS: Please fill in your details below, sign and date this form, and attach a copy of your
passport photo page where indicated. Then, send a copy of this completed form to:
immigration.department@becomeacanadian.org

FIRST NAME: _______________________________ LAST NAME: ______________________________________

FILE NUMBER: ________________ DATE OF BIRTH: ______________COUNTRY OF BIRTH: __________________

VISA TYPE: Permanent Residence DESIRED DESTINATION: Canada

STREET NUMBER & STREET NAME: _______________________________________________________________

CITY/TOWN: __________________________________STATE/PROVINCE: ________________________________

POSTAL/ZIP CODE: _______________________ COUNTRY: ____________________________________________

HOME PHONE: _________________________________ MOBILE PHONE: ________________________________

BY SIGNING BELOW, I CONFIRM THAT THE INFORMATION ON THIS PAGE IS ACCURATE.

____________________________________ ________________________________ ____________________

FIRST AND LAST NAME SIGNATURE DATE SIGNED

Please attach a copy of your passport photo page here.