Citizenship and Citovennet et PROTECTED WHEN COMPLETED- B
immigration Canada immgration Camada PAGE 1 OF 3
REQUEST TO AMENDTHE RECORD OF LANDING (IMM 1000), CONFIRMATION OF PERMANENT
RESIDENCE (|MM 5292 or IMM 5688)OR VALID TEMPORARY RESIDENT DOCUMENTS
PART A PERSONAL DETAILS CONTAINED ON YoUR IMM 1000, IMIM 6292 |1] Cent iD numter/UCI
OR IMN 5688, OR VALID TEMPORARY RESIDENT DOCUMENTS
|2|Surnameis) (Faily rane) (As dcurnently appears on your documarnt) 3Given natne(s) (As it currerity appears on your document)
PALLIKKOO DTHILCH) NASIE HuSSGn
4OthÍr name's) u5ed 5 Otgr gven nare(s) usnd |6 SaK
Maie Femaie
7 Date of brth 8 Place of brth (Cty stale'prvince and country) |9 Cibzership
YYYY MMOC
THoDupU2 HA, IDUKI teERALA, INDIA
10| Pasxprt number irdk:ale it
NGEIB46 On entryCurent
Date |12 Expiry loa6-YrY-A-0D
03- o
dale
YrYY-OD
13 Marta status
If you ae married, i6 your spouse
Never manecd VMarried Canad.an citzer or permanent resident?
Widowed Separated Divorcod Cornmon-law partner
Larguage of corespordence English French
|15| Current mailing address
At./Unit Sreet náme
MUvGTTUpUZHA PETTA
CtyiTown Postal code District
Country ProvincoSlate
MUVATTUPUZHA |NDIA kERALA 6866GI ERNGKULA M
WResdenta edtess Same as madg sduress?
Apt.font Straat no. Street nama CityfTon
PeTTA MUVATTUPUZ HA
Counry Provino/Slate Postal Gode Dstrict
NDIA ICERGLA 66661 ERNAkuLAMn
1|Telephone no Canadaus 18| Aet nsite Telephone nú |Canada/US Oter
Type Country Code No Ext. TYpe Gountry Çode No. Et.
MOBILE +q1Ga3SOi46o
19| E-mailaddress: {indicatng an e-mailaddress wliluthorize al corresporderce, including fie arnd personal inforration, to be sent to the e-mail address you speciy)
hazzhussaih 36 gail- com
20 2Date pernarent residence or
Date of orginal enry tenporary residercs was granted
YYYM4-D0 YYYM-OD
PART B-INFORMATION TO BE AMENDED
|1|Piease zrdicate tor wich of the folkzwing you hd a chrection. I# yu have rKare Ihan cne valid temporary resident docunent,idicate the docurrent DAurnaer of if
unkricwh the docunent isSUe dale rd expiry datë it e ëSlad diuMent.
iugrart Visa and Record ot ianding
Corifmatcn of ernanent Resisience Excusior Drder LDeparture Order
Pernit lo Come inlo ce Renain n Canada .
Authorization to Return to Canada Temgorary Resdent Permit Protected Person
OR igse dale
Vork Permit ID No Expry date
(YY-DO)
OR 0sSie dste:
|Study Permit
i9sue date Expy date
Vistor Record I0No
rYYYAAI-DD
This torrn is rnade avalable by Citlzenship and irnmigratlon Canada and is not to be sold to
(AUSSI DISPONI8LE EN FRANÇAIS -MIM 1436 F)
appilcants.
Canadä
NASIF Huss enN
