Professional Documents
Culture Documents
Application Summary
Representative
Telephone numbers
100-150 Carlton St
Address Toronto Ontario M5A 2K1
Canada
Did you already make a claim to an officer when you entered Canada (for
Yes
example: land border, airport)?
Personal Information
Gender Male
Nationality
Choose the country code that matches the one on your passport Kenya
Group information
Do you want to apply for more than 1 person at the same time? No
Personal Information
Gender Male
Height In centimetres
Centimetres 175
Other identities
Other names
Contact information
129 Peter St
Address Toronto Ontario M5V 2H3
Canada
100-150 Carlton St
Address Toronto Ontario M5A 2K1
Canada
unknown
Address
Mombasa
Kenya
Status Citizen
unknown
Address
Kitui
Kenya
Status Citizen
Juja
Address
Kiambu
Kenya
Status Citizen
Telephone numbers
Nationality
Children
Do you have any children (biological, adopted or step-children) who are not
No
already included in this claim?
I understand I’m not declaring any other biological or adopted children or step-
children.
Parents
Relationship Mother
Embakasi
Address
Nairobi
Kenya
Relationship Father
Embakasi
Address
Nairobi
Kenya
Guardian
Do you have a guardian because you can’t understand the proceedings or you’re
No
under 18 years of age?
Address
Canada
Travel to Canada
Route to Canada
Country/territory Kenya
Country/territory Ethiopia
Country/territory Ethiopia
Country/territory Ireland
Country/territory Ireland
Country/territory Canada
Are you currently studying or have you ever studied at a post-secondary school? Yes
Study programs
Did you get a degree, diploma or certificate after completing this program? Degree
Address Juja
Kenya
Give details of all your employment and activities for the past 10 years.
Date started 2023-09
Address Nairobi
Kenya
Address Dublin
Ireland
Address Nairobi
Kenya
Address Kiambu
Kenya
Address Nairobi
Kenya
Address Nairobi
Kenya
Address Kitui
Kenya
Address Mombasa
Kenya
Government positions
Did you serve in any military, militia, civil defence unit, security organization or
No
police force?
Criminality
Have you ever been arrested for any criminal offence in any country or territory
No
(this includes driving under the influence of alcohol or drugs)?
Have you ever been charged, sought, or wanted for a crime in any country or
No
territory?
Have you ever committed any crime in any country or territory (this includes
No
driving under the influence of alcohol or drugs)?
Admissibility
Have you supported, been a member of, or been associated with any
No
organizations?
Have you supported, been a member of, or been associated with any
organizations that uses, used, advocated or advocates the use of armed struggle No
or violence to reach political, religious, or social objectives?
Have you been a member of any organization that is or was engaged in criminal
No
activity?
Have you ever used, planned, or advocated the use of armed struggle or violence
No
to reach political, social or religious objectives?
Have you ever had any serious disease, or physical or mental disorder? No
Travel history
In the past 10 years have you travelled to a country or territory other than where
No
you live now or where you're a citizen?
Has Canada or any other country ever refused to issue you a visa or permit,
No
denied you entry to the country, or ordered you to leave?
Are you a lawful permanent resident of the United States (U.S.) with a valid green
No
card (alien registration card)?
Have you held a Canadian visitor visa in the past 10 years? Yes
Refugee background
Relationship Agent
unknown
Address
Nairobi
Kenya
Are you afraid to return to your home country (or territory) or the country (or
Yes
territory) where you normally live?
Country/territory Kenya
Why are you unwilling or unable to return to your home country (or territory) or the
Please see the narrative when submitted.
country (or territory) where you normally live?
Why did you not move to another part of your home country (or territory) or the
Please see the narrative when submitted.
country (or territory) where you normally live?
Did you ask police for help in your home country (or territory) or the country (or
No
territory) where you normally live?
Why didn’t you ask the police for help? Please see the narrative when submitted.
Why did you decide to come to Canada (instead of another country or territory)? Please see the narrative when submitted.
Have you ever made a claim for refugee protection in any of the following places:
The information you provided in this application is collected under the authority of the Immigration and Refugee Protection Act. It will be used to render
a decision regarding this application and may be used for future applications. The information is retained to maintain a record of your application for
the purpose of the administration of the Act. The information will be retained in the Personal Information Banks CIC PPU 051, CIC PPU 054, or CIC PPU
055, depending on the type of application made, as well as in CIC APB 012, and CIC PPU 042. The information may be disclosed to other organizations
such as the Canada Border Services Agency (CBSA), the Royal Canadian Mounted Police (RCMP), the Canadian Security Intelligence Service (CSIS), the
Employment and Social Development Canada (ESDC), provincial/territorial and foreign governments in accordance with subsection 8(2) of the Privacy
Act. In accordance with the Privacy Act and the Access to Information Act individuals have the right to protection of and access to their personal
information. Details on these matters are available at the Infosource website (https://www.infosource.gc.ca) and through the Citizenship and
Immigration Canada website (https://www.cic.gc.ca/english/department/atip/index.asp). Infosource is also available at Public Libraries across
Canada.
Declaration of Representative
I have read and understand the above Notice Regarding Personal Information.
I declare that, to the best of my knowledge, the information in this application is truthful, complete and correct. I declare that the applicant has reviewed
the entire application, including any supporting documents.
I understand that misrepresentation is an offence under section 127 of the Immigration and Refugee Protection Act and may result in a conviction and
penalty under the Act.
I solemnly declare that the information I have provided is true and that the documents I am submitting in support of my clients' applications are genuine
and have not been altered in any way.
Signature
I agree that by submitting this application, I have been duly authorized by my client, the applicant, to submit this application on his or her behalf.