s lmpwgration, Aefugies COMPLET

lm'!}gtation, Ae(ugee PROTECTED WHEN

an d Citizenship Cana
da et CitoyeMat6 Canada
& -- Page

io k c,c us~ ONLy

SCHEDULE A Client IDIUCIIFOSS ID
C L A R A T IO N
B A C K G R O U N D /D E
can also print II w.cic.gc.ca
• form. ma ke enough photooop,e
plet,ng th •s
•
s for you r needs. You a or part of this form
from our Web site at ww
Before you start com •
r
ails. Print your -name
. at tl'le t
all the a se det
Ir thefe not enough
ce to ~Y ide to this 'form et pap er with further op o each a<tdtl
spa
ary inforrnatJ'on. attach par ate She dt
nec ess wering.
form's title and the num ber of the question you are ans
she et and ind ica te the
BE FO RE YO U ST AR
TY PE or PR INT In bla
T R .
~k ,:o
THE INSTRUCTION
GUIDE

u arv
/ Ind ica te wll elh er yo l applicant
dep e . rs or older of the principa
n-law partner or ndent child aged 18 yea
D Th e principal app lica
nt 0 The spouse, commo

1. Yo urf u& na me Given name(s)

Fam ily nam e Sa:r.dn
"t,h al iq i / 1 You r dat e of birt
h (YY YY-MM-O
ti ipt
e wri tten .In your_na, . ve ~n gu ag e !)r scr te,s or Ch,nese ~mme,ri.,,,1r...s.;,.;,,.· • ·- -
2. Yo ur fulf· Mm -~ ra ph 1c <:Ode) 19 98 -12 12
(e . .
rft . Kor ean. Jap ane se Chatae
.g. Arabic. Cv Ch ,~ .
I

_,.....L.: :.., .:,.....,_,

of yo ur fat her Given name(s)

~- Personal details
Fam dyn am e Ah::r.ad s:i ah -OO )
Dam of dea lt. l dec
aased (YY YY -IN
Kh al i qi ,......L" birt h
Country or territory of
-MM -00 ) Tow n/C ity of birth Af gh an ist an
Da te ot birt h (YY YY b
Fa rya
19 70 -C 7-2 8
of yo ur mo the r Given name(s)
5. Pe no na l details
Mo nir a J~
Fam ily nam e at birt h Dat e of d91 1. t deceased (Y YY Y~ O)
Kh ali qi bfrth
Country or territory of
Y~ OO ) Tow n/C ity ot birth Af gh an ist an
Da te of btrth (Y YY ... . ew r:
Fa rya b ent rnt den ce 1n c..
19 76 -12 -27 el'9 l'9t ed In you r 1ppflcaUon tor pennan
pal app lica nt, any of you r fam ily memb YES NO
6. Ha ve )'OU , or, ff
yo u are the pri nci
Criminal RtJcorrJs Act
of Canada? 00
par don has not been granted under the
a) been convicted of
a crim e or offence in
Canada tor whi ch a
. or su bj~ ol any crim
iNII proceedings ,n any
other
00
tly charged with. on tria l °'
tor. par ty to a crime or offence
b) bee n convicted
of, or are you curren
any other counlry(ies)
or temto,y(ies), or wrth
the 00 I
cou ntry or terr itor y?
or at a Can adi an visa office abroad, In j
tion in Canada
ms for refugee protec
c) ma de p,eVIOUS dai
s Hig h Co mm issi oner for Refugees (UN
HC R)?
C~ c1 1I dtl selection
du ~b ee (CSO) or
appkation to the 00
Un ited Nation nt visa (ind Jdl ng a
nt or permanent reside other country or temto,y
?
gee status, an ,mm,gra t visa. to Canada or any 0 fl]
d) bee n refused refu or visi tor or temparary res den -- -
ee Pro gra m)
Provinc,al Nomtn ntry or temtory?
adm issr on to. or ordered to leave. Can
ada or any other cou 0 0
e) bee n refused e against humanity?
in an act of gen ocid e. a wa r cri me °' in the
commission or a crim
ectives?
0 @
f) bee n involved l. ret,g,ous or social ot>,
ted the use of armed stJu ggle or vlol
ence to reach pol,ttea
to reach pol1lical. relig
,ous or socialO 0
adv oca ggle or v'°'8 nce
g) used, planned or oca les the use of armed stru
h) bee n assocaaled with
a group that used. use
s. ·advoc ate d or adv
00
?
tern ot criminal activity 00
objectives? ivity that ls part ot a pat
anlz.aU on tha t Is or was ,mgaged In an act
i) bee n me mb ef of
an org
00
incarcerated or put in jail ? I
j) bee n detained

dis eas e or physical

or mental disorder?
k) had any serious ails below.
of these questio ns 1s YES. provide det
If your anawer to any

to appltcanm.
and • not co l>e aolcf
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Thia fon n I• " - • av•
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and Imm igra tion C.n ad•
Ca11ada
5669 F)
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A. , Page 2 of 4

7. Education
Grve the number of years of school you successfully completed for each of the following levels of educabon.

Q Etementary/
primary school
Q Secondary,
high school
Q University/
college
D Trade sehool or other
post secondary school

Gtve Ml details of all the secondary and post secondary education (including universtty, college ind apprenticeship training)
you have had.
Type of certificate ·or Field of study
From -To City and country or territory
Name of fnatitutlon dlploma Issued
(YYYY-MII) (YYYY-MM)
faryab, Afgharus Ldn O.iploma General Sludy
2004-04 20:6-12 ::.isa Salara
Mazar-i-Shar if, Afgha sti;dent
2017-04 2021-07 Rahnaward University

8. Personal history
•
Provide the details of your personal history since the age of 18. or the past 10 years, whichever is most recent
not wor1dng. provide information on what you were doing
Start with 1he most recent information. Under "Activity". write your occupation or job tiUe if you were working. ff you were
nabonality, incfica1e your status in that country or territory.
(for example: unemployed. studying, travelling, retired. in detention. etc.). If you were outside your country or territoty of

Note: Pr.as. wunrthatyou do not leave any gaps in lime.

,o Failure to account for al time periods wl result in a delay in the processing d your application.
. . . . lif company. emplOyer.
FroJn To Activity
Ctly or town SWus Jn country
and country or territory or territory school, faclity. as applicable
(YYYY-IIM) (YYYY-IIM)
2023-12 unemployed Isla:nabad Pdr..ista:i ~/A
2023-01

2022-12 unemployed ~:azar-i-Shar if Afghanistan ~/A

2021-07

20:1-01 2021-07 Student r,~azer-i-shar i f Afghanistan Medi ca:. study

9. Membership of auoclatlon with organiz.ations

01 student organazabon, trade unions and professional
Wlat organ,zat,ons have you supported, been a member of or been associated with? Include any poltical, sooal. youth
assooabons. Oo not use abbreviations. tnd,cate the crty and country or temtory where you were a member.
Wile "NONE· in the box it you have not been a member of any association/organization.

From To ActtvltlN andlaf posttions City and coun1ry

Name of organlzlUon Type of o,ganiutlon
(YYYY. .) (YYYY-IIM) Mid within o,pnintion ortenitary

NONE

10. Government positions

held. Include posibons you have held before or afte,
List any government positions (such as CIVIi servant. Judge, police officer. employee in a secunly o,ganization) you have
your retirement Oo not use abbreviabons. Write ·NONE" 1n lhe box 1f you have not held any government pos1t1ons.

Country or territory and level of

From To Department/Branch ActMtltl andlor positions held
JurtscUcUon(e.g. national, regional,
(YYYY-1111) (YYYY-IIM) munlclpaJ)

NONE

MM 5689 (0S-2021) E
I (
•
I - • Page 3 of 4

r pa ram ilit ary service

11. Military an dlo armed forces you
served
•
•litary and/or paramitta ~~ MC e for ~~ch of the couDo ntnes in whose
any gaps in ume.
•
mp let ed 1a·1
, s of mt ita e. not leave
Pro.vid"e below .co e no t undertaken mil or param ilitary se,vic
ve
the box if you ha ry
Write NONE" Hl

territory Jrmrz:::
1
Name c:A a" mt ,y
or Reason for ffld of
Oates and places Se rvi ce
and at
Branch of aerric
e, unft numbers Rank(s) of any active comb
Fro m
To
s of yo ur co mm anding officers
(YYYY-1111) name
(YY YY -IIM )

-- -
-
.- - - -

.. -- - - - -
-

1
or territory /NON:£
Name of ax mt ry Reason few end
of
s
Da tn an dp lau ser vic e
and of .,,. , actlYe co
mbat
, un it numbers Rankfs)
To Branch of service an din g officers
ur co mm
Fro m names of yo
'(YYYY-MM)
(YYYY-4111)

.
P.O box addresses
recent Do no t use
rs, whichever Is mosl l code/ ,y
12. .Addl'esses or the past 10 yea Po sta Co un try or ter rllo
your 18th birthday Province, Stat. or Zip co de
s where you have l,ved since tow n Dla lric t
List al addresse City Of'
I er ?« k1 std r.
To Sttwet and numb <l 44 00 0
From fc Jc rd l C« pit
YY-MM) r sl..1mc1b<1d At ga ni sta n
(YYYY-MM)
(YY
St re et 1J ,
Ho us e 17 3
Ba lk h
-
20 23 -0 1
20 23 -1 2 M a: dr -i- Sh <.1 cif Af gd ni std n
Ap pc lrt mc nt
88 -
St re et 5, f JC ~'d b
20 23 -1 2 Ma1mand At qa ni sta n
20 23 -0 1
St re et 4, Ho
us e l
Ba lkh
-
if
20 2? -1 2 M cl: :d r-i -S hc 1r A. fg dn ist dn
20 21 -0 8
St re et 18 ,
!lo us e 3
faq ,c1 b
-
20 21 -0 7 Md l md nd
20 17 -0 1, us c l
St re et 4, Ho
20 1 ·1- c2
20 04 -0 1

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021) E
IMM 5669 C0!>-2
Authority to dlsclm • personal lnfonna tlon t lhority • including
police. Judicial and
Thi
.
to the release to Canadia n governm ent authorities of all records and 1nformabon any governmen au convictio ns a
nd 1
sen ences. s
By submitting thas fonn you consent concern ing any 1nvestigat1ons. arrests. ~arge~ . trials.
may possess on your behalf
state authorities In al countries in which you have lived t to Canadian leg,slatlon.
y for adffllssion to Canada or remaining 111 Canada ptD'suan
mformabon will be used ID aSStst in evaluati\g your suitabilit

Declaf'l tion of applkant

and correct.
I declare that the infonnation I have given ls truthful. complete

Date (YYYY-MM-OO)
Signature
OF A REPRESENTATIVE OF THE CANADIAN
YOU MAY BE ASKED TO SIGN IN THE PRESENCE
DO NOT COMPt:ETE THE FOLLOWING SECTION NOW.
CANADIAN GOVER NMENT.
GOVERNMENT OR AN OFFICIAL APPOINTED BY THE

Interpre ter declaration

ly interpreted 1n the
. do solemnly declare lhal I have faithfully and accurate
I.
forms to the person concerned.
language the content of this application and any related
and effect of these forms. and I make trus soJemn
verily believe, that they completely understands the nature
I haw been informed by the person ccncemed. and I do as rs made under oath.
that it is of the same force and effect
declaration e011scientiousty believing it to be true and knowing

Signature of interpreter

Solemn declaration
in the foregoing
. do solemnly declare that the information I have given
I,
it is of tne same force and effect as 1f
on conscientiously beheving it to be true and knowing that
appicabOn is truthful, complete and correct. and I make this solemn declarati
made under oath.

Signature of applicant
otthe year
this day of
Dedared before me at

Signature
canadian government official Name (Please pnnt or type)

collected by lmmi rat' R tu under the authonty of the lmmigrabon and Refugee
Personal informabon p<ovided on this form is on used forgtheic;>:,po:e ~es;=~ rtizens h1p Canada (IRCC)
Pfoledion Ad (IRPA). The personal informati Wtll be ~ng an appl;ca =-.. pe,sona l informabon provided may be disclosed to other
inf0tmation and ehgi~lity
federal govem_me~t i~stltu~ s for the purpose of vahdating ~V al:::s :,~n ed lotion ~-y also be di'sctosed to law enforcement bodies lor the
r:rpose of validat~ng identity_. eligibility and adm1S11 bility. The personal information i s provinoal/temtonal governments and foreign governm
ents for
e purpose of validabng ellgibll,ty and admiuibtMy.

Pet10nal informabOn may also be used for other purposes inciud,ng research stat istics • program and policy evatuabon. internal audit. compliance. program ,ntegnty, nsk
ent and reporb~g.
management. subsequent p,ogram ehg1b1l1ty, strategy developm
. . .
Fallure to complete the form in fuU may result In 8 delay or the apphcat,on not being processed. The Pnva Ad gives • •
individuals the nght of access to. protection • and
correction of their personal ,nr . If you are not satisfied with the manner in Which IRCC handle5 your cy
l 1nformat 10n you ma 8
complaint to the ormahon . persona
The ---Ii l in.....:__..,__ Y xercise your nght to file a
• ..-..JOn , use, c.tisdos4q and ,.tention ot your persona .....,.__. is further described in IRCC's
Personal Information Bank - IRCC PPU 009 . 013 · 039 · 042

IMM 5669 (05-2021) E