1.2.

QUESTIONS 1295

Have you previously married or in a common law relationship different from your current one? Yes
Provide the details for your previous spouse/common law partner: No

Family Name Given name

Date of birth yyyy-mm-dd Type of relationship From yyyy-mm-dd To yyyy-mm-dd

Native Language Please write your official language or another native language

During the past five years have you lived in a country or territory other than your country of citizenship or
your current country or territory of residence? if apply, please provide country status and dates
Country Status From to

Passport Number Country or territory of issue Issue date yyyy-mm-dd Expire date yyyy-mm-
dd

Current country or territory of residence:

Country Status From yyyy-mm-dd To yyyy-mm-dd
 1.2. QUESTIONS 1295

Have you had any post secondary education (including university, college or apprenticeship training?

Yes No

If you answer “yes” give full details of your highest level of post secondary education

From YYYY - MM Field and level of study School/Facility Name

To YYYY - MM City/Town Country

From YYYY - MM Field and level of study School/Facility Name

To YYYY - MM City/Town Country

2
 1.2. QUESTIONS 1295
NO YES
Within the past two years, have you or a family member ever had tuberculosis of the lungs
1 or been in close contact with a person with tuberculosis?
Do you have any physical or mental disorder that would require social and/or health
2 services, other than medications, during a stay in Canada?
Have you ever remained beyond the validity of your status, attended school without
3 authorization or worked without authorization in Canada?
Have you ever been refused a visa or permit, denied entry or ordered to leave Canada or
4 any other country or territory?

5 Have you previously applied to enter or remain in Canada?

Have you ever committed, been arrested for, been charged with, or convicted of any
6 criminal offence in any country or territory?
Didi you serve in any military, militia, or civil defence unit or serve in a security
organization or police force (including non obligatory national service, reserve or volunteer
7 units?
Are you, or have you ever been a member or associated with any political party, or other
group pr organization which has engaged in or advocated violence as a means to achieving
a political or religious objective, or which has been associated with criminal activity at any
8 time?
Have you ever witnessed or participated in the treatment of prisoners or civilians, looting
9 or desecration of religious building?
If you answered yes to questions 1 to 9 please provide details and the name of the family member (if applicable)