Application Summary Group Information

Luidmila Semivolos (V400760032) Protected B
Application Summary
Group information
Do you want to apply for more than 1 person at the same time? Yes
Group type Family
Group name Shelipov family
Application for a visitor visa
I want to apply for a: Canada-Ukraine authorization for emergency travel (CUAET)
I am a Ukrainian national who holds a Ukrainian passport or

Are you a Ukrainian national or an immediate family member?
other travel document
Do you want to work while you're in Canada? No
Select the province or territory where you plan to live or work Unknown
Representative
Are you applying on behalf of someone else? No
Date modified: 2022-08-03 11:07:00 UTCZ Page 1 of 12

Travel document information of the applicant
Surname/last name Semivolos
Given name/first name Luidmila
Date of birth 1951-05-20
Gender Female
What document are you travelling with? Passport
What kind of passport? Regular
Select the country code that matches the one on your passport UKR (Ukraine)
What's the nationality on your passport? Russia
What's your passport or travel document number? FF939297
Confirm your passport or travel document number FF939297
When was the passport issued? 2017-03-22
Date of expiry of the passport 2027-03-22
Are you a lawful permanent resident of the United States with a valid Green Card (alien
No
registration card)?
Have you held a Canadian visitor visa in the past 10 years? No
Do you currently hold a valid U.S. nonimmigrant visa? No
Are you travelling to Canada by air? Yes
Citizenship and places where the applicant has lived
Country or territory where you were born Russia
City or town where you were born Irkutsk
Are you a citizen of more than one country or territory ? No
Which country or territory are you a citizen of?
Country/territory of issue Ukraine
From 1991-08-24
National identity document of the applicant
Do you have a valid national identity document? Yes
Document number FF939297
Confirm your document number FF939297
Date of issue 2017-03-22
Select the country or territory that issued this document Ukraine

Names used in the past
Have you used another name in the past? Yes
What type of name? Name before marriage
Surname/last name Bogush
Contact information of the applicant
9, Morcinka str
Address Tychy 43-100
Poland
Is your mailing address the same as your residential address? Yes
List your current country or territory of residence, then add all other countries or territories where you've lived for the past five
years, for more than 6 months.
Country/territory Poland
Status Visitor
From 2022-03-06
To 2022-08-03
This is where I currently live.
Country/territory Ukraine
Status Citizen
From 2020-06-03
To 2022-03-06
Country/territory Russia
Status Visitor
From 2019-08-24
To 2020-06-03
Country/territory Ukraine
Status Citizen
From 2017-08-02
To 2019-08-24
Biometrics (fingerprints and photo) of the applicant
Do we already have your fingerprints and photo (biometrics), and are they still valid? No

Information about education, work and other activities
Post-secondary education history
Have you ever studied at a post-secondary school (university, college or vocational school)?
Yes
You don't need to have completed a degree or diploma.
Give details of each program you have studied and are

Dnipropetrovsk State Theater School
currently studying.
From 1966-09
Level of study Secondary School
Field of study Arts, Fine/Visual/Performing
To 1969-06
4, Glinky str
Address Dnipro
Ukraine
Work/activities history
Military/police history
Did you serve in any military, militia, civil defence unit, security organization or police force
No
(including non-obligatory service, reserve or voluntary units)?

Give details of all your employment and activities for the past 10 years.
From 2014-04
To 2016-08
Work/Activity Art, culture, recreation and sport occupations
Job title Musician
Company/employer children's preschool education institution No. 1
Main duties of the job artistic director
75, Centralyna
Address Petrikivka
Ukraine
From 2016-08
Ongoing
Work/Activity Retired
65, Shevchenko str

Address Loboykivka
Ukraine
From 2012-04
To 2014-04
Work/Activity Retired
65, Shevchenko str

Address Loboykivka
Ukraine

Travel history
During the past 5 years have you travelled to a country or territory other than the one where
Yes
you're a citizen or where you live now?
From 2022-07
To 2022-07
Country/territory Croatia
Location/place where stationed Omish
Purpose of travel tourist
From 2021-05
To 2021-06
Country/territory Turkey
Location/place where stationed Antaliy
From 2018-08
To 2018-09
Country/territory Egypt
Location/place where stationed Sharm El-Sheikh
From 2017-08
To 2017-08
Country/territory Turkey
Location/place where stationed Marmaris
Have you ever stayed in Canada beyond the validity of your status, attended school in Canada
No
without authorization, or worked without authorization in Canada?
Have you ever been refused a visa or permit, denied entry to, or ordered to leave any country or
No
territory?

Criminality and security
Have you ever committed any crime in any country or territory (this includes driving under the
No
influence of alcohol or drugs)?
Have you ever been arrested for any criminal offence in any country or territory (this includes
No
driving under the influence of alcohol or drugs)?
Have you ever been charged for any criminal offence in any country or territory (this includes
No
Have you ever been convicted for any criminal offence in any country or territory (this includes
No
Criminality and security questions
Are you or have you ever been a member associated with any political party, or other group or
organization which has engaged in or advanced violence as a means to achieving a political or No
religious objective, or which has been associated with criminal activity at any time?
Have you ever witnessed or participated in the ill treatment of prisoners or civilians, looting or
No
desecration of religious buildings?
Medical background questions
Have you had a medical exam performed by an IRCC authorized panel physician (doctor) within
No
the last 12 months?
I acknowledge that the immigration medical examination that is required as part of this
immigration application is being waived, and that a condition may be added to my temporary
resident status upon arrival in Canada stating that I will need to obtain a chest x-ray (or suitable
alternative) and blood test for the purposes of detecting reportable communicable disease
within 90 days of my arrival. Immigration, Refugees and Citizenship Canada will use the results
of the tests to ensure appropriate identification of reportable communicable diseases in order
to mitigate risks to public health and safety, including by sharing the results with provinces and
territories. I hereby consent to submit to these tests.
Medical background questions- Tuberculosis
In the last 2 years, were you diagnosed with tuberculosis? No
In the last 5 years, have you been in close contact with a person with tuberculosis? No
Medical background questions
Are you currently receiving dialysis treatment? No
Have you had a drug or alcohol addiction causing you to be a threat to yourself or others, or to
No
be hospitalized?
Have you had a mental health condition causing you to be a threat to yourself or others, or to
No
be hospitalized?
Have you ever been diagnosed with syphilis? No

Family information
What is your current marital status? Widowed
Date of marriage or start of common-law relationship 1969-07-26
Name of spouse/common-law partner
Given name/first name Georgiy
Country or territory of birth Ukraine
When did the relationship with your spouse or common-law

2016-11-08
partner end?

Children
Do you have any biological, adopted or step-children? Yes
Surname/last name Shelipov
Given name/first name Artyom
Relationship Son
Does this child have the same address as you? No
99, Svoboda Avenue

Present Address Dnipro 49000
Ukraine
If the child is not in Canada, will they accompany you to

No
Canada?
Given name/first name Evgeniy
Relationship Son
34, Malinovskogo avenue

Ukraine

No
Canada?
Surname/last name Shelipova
Given name/first name Zinaida
Relationship Daughter
47, Kalinova str

Ukraine

Yes
Canada?

Tell us about your parents
Surname/last name Bogush
Given name/first name Ivan
Relationship Father
This parent is deceased.
Date of death 1988-05-13
Language of the applicant
What is your native language or mother tongue? Ukrainian
Can you communicate in English and/or French? Neither
What language do you want us to use to contact you? English
Email address of applicant
Email address dmmih1980@gmail.com
Confirm your email address dmmih1980@gmail.com
Telephone number of the applicant
Telephone type Cellular
Select telephone number country or territory Other
Telephone number +48 883162962

Documents to support your application
Document name National identity document
File name pass ukr.pdf
Size of the Document 834.00 KB
Date/time uploaded 2022-08-03 11:07:00 UTCZ
Document name Passport/travel document
File name pass int.pdf
Document name Funds (proof)
File name bank all.pdf
Document name Additional documents
File name birth sert.jpg
Fees
Fee Quantity Price Total
Visitor visa 1 CAN$100 CAN$0
Total CAN$0
Consent and declaration
Citizenship and Immigration Canada (CIC), or an organization at CIC's request, may want to contact you in the future to ask you
about any services you received from CIC prior to the application process (such as participation in an information forum), during
the application process (including the application process itself as well as orientation or accreditation services), and services
received after arriving in Canada (including settlement, integration and citizenship). CIC will use this information, along with the
information provided by other individuals, for research, performance measurement or evaluation purposes. CIC will not use this
information to make any decisions about you personally.
Do you consent to be contacted by CIC, or an organization at CIC's request, in the future? Yes
I consent to the release to Citizenship and Immigration Canada (CIC) and Canada Border Services Agency (CBSA) of all records
and information for the purpose of processing my request that any government authority, including police, judicial and state
authorities in all countries in which I have lived may possess about me. This information will be used to evaluate my suitability
for admission to Canada or to remain in Canada pursuant to Canadian legislation.

I declare that I have answered all questions in this application fully and truthfully.
Signature of Applicant or Parent/Legal Guardian's for a person under 18 years of age.
Privacy Notice
Personal information provided on this form is collected and will be used, disclosed, and retained by Immigration, Refugees and
Citizenship Canada (IRCC) under the authority of the Immigration and Refugee Protection Act (IRPA). The personal information
provided will be used for the purpose of processing applications. The personal information provided may be disclosed to other
federal government institutions and third parties including law enforcement bodies, provincial/territorial governments and/or
foreign governments for the purpose of validating identity, eligibility and admissibility.
The personal information collected on an application, and other information collected in support of an application, may be used
for computer analytics to support processing of applications and decision making, including your application. Personal
information, including from computer analytics, may also be used for purposes including research, statistics, program and policy
evaluation, internal audit, compliance, risk management, strategy development and reporting.
Where biometrics are provided in support of an application, the fingerprints collected will be stored and shared with the RCMP.
The fingerprint record may also be disclosed to law enforcement agencies in Canada in accordance with subsection 13.11(1) of
the Immigration and Refugee Protection Regulations. The information may be used to establish or verify the identity of a person
in order to prevent, investigate, or prosecute an offence under any law of Canada or a Province. This information may also be
used to establish or verify the identity of an individual whose identity cannot reasonably be otherwise established or verified
because of physical or mental condition. Canada may also share immigration information related to biometric records with
foreign governments with whom Canada has an agreement or arrangement.
Failure to complete the form in full may result in a delay or the application not being processed. The Privacy Act gives individuals
the right of access to, protection, and correction of their personal information. Further details are available in Info Source. If you
are not satisfied with the manner in which IRCC handles your personal information, you may exercise your right to file a
complaint to the Office of the Privacy Commissioner of Canada. The collection, use, disclosure and retention of your personal
information is further described in IRCC's personal information bank - IRCC PPU 068.

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Luidmila Semivolos (V400760032) Protected B

Group type Family

Group name Shelipov family

Application for a visitor visa

I want to apply for a: Canada-Ukraine authorization for emergency travel (CUAET)

I am a Ukrainian national who holds a Ukrainian passport or

Do you want to work while you're in Canada? No

Are you applying on behalf of someone else? No

Date modified: 2022-08-03 11:07:00 UTCZ Page 1 of 12

Travel document information of the applicant

Surname/last name Semivolos

Given name/first name Luidmila

Date of birth 1951-05-20

What document are you travelling with? Passport

What kind of passport? Regular

What's the nationality on your passport? Russia

What's your passport or travel document number? FF939297

Confirm your passport or travel document number FF939297

When was the passport issued? 2017-03-22

Date of expiry of the passport 2027-03-22

Have you held a Canadian visitor visa in the past 10 years? No

Do you currently hold a valid U.S. nonimmigrant visa? No

Are you travelling to Canada by air? Yes

Citizenship and places where the applicant has lived

Country or territory where you were born Russia

City or town where you were born Irkutsk

Are you a citizen of more than one country or territory ? No

Which country or territory are you a citizen of?

Country/territory of issue Ukraine

National identity document of the applicant

Do you have a valid national identity document? Yes

Document number FF939297

Confirm your document number FF939297

Date of issue 2017-03-22

Select the country or territory that issued this document Ukraine

Date modified: 2022-08-03 11:07:00 UTCZ Page 2 of 12

Names used in the past

Have you used another name in the past? Yes

What type of name? Name before marriage

Surname/last name Bogush

Given name/first name Luidmila

Contact information of the applicant

Is your mailing address the same as your residential address? Yes

This is where I currently live.

Biometrics (fingerprints and photo) of the applicant

Date modified: 2022-08-03 11:07:00 UTCZ Page 3 of 12

Information about education, work and other activities

Post-secondary education history

Give details of each program you have studied and are

Level of study Secondary School

Field of study Arts, Fine/Visual/Performing

Date modified: 2022-08-03 11:07:00 UTCZ Page 4 of 12

Work/Activity Art, culture, recreation and sport occupations

Job title Musician

Company/employer children's preschool education institution No. 1

Main duties of the job artistic director

65, Shevchenko str

65, Shevchenko str

Date modified: 2022-08-03 11:07:00 UTCZ Page 5 of 12

Location/place where stationed Omish

Purpose of travel tourist

Location/place where stationed Antaliy