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    IMM5743E

    Uploaded by

    Wuilmer B. Guerrero
    The document is a consent form for a client's immigration medical examination submitted to Citizenship and Immigration Canada (CIC). It contains the following key points: 1) The client declares that all medical information provided is true and consents to their medical results being collected and reported to CIC. 2) CIC may release the client's medical information to other government agencies in Canada and collect additional medical information about the client from agencies in Canada. 3) The client's information will be used to make a decision on their immigration application and may be used for future applications, and will be kept on file by CIC according to its privacy policies. 4) The client acknowledges they understand and provide their consent voluntarily

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    IMM5743E

    Uploaded by

    Wuilmer B. Guerrero
    807 views0 pages
    The document is a consent form for a client's immigration medical examination submitted to Citizenship and Immigration Canada (CIC). It contains the following key points: 1) The client declares that all medical information provided is true and consents to their medical results being collected and reported to CIC. 2) CIC may release the client's medical information to other government agencies in Canada and collect additional medical information about the client from agencies in Canada. 3) The client's information will be used to make a decision on their immigration application and may be used for future applications, and will be kept on file by CIC according to its privacy policies. 4) The client acknowledges they understand and provide their consent voluntarily

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    The document is a consent form for a client's immigration medical examination submitted to Citizenship and Immigration Canada (CIC). It contains the following key points: 1) The client declares that all medical information provided is true and consents to their medical results being collected and reported to CIC. 2) CIC may release the client's medical information to other government agencies in Canada and collect additional medical information about the client from agencies in Canada. 3) The client's information will be used to make a decision on their immigration application and may be used for future applications, and will be kept on file by CIC according to its privacy policies. 4) The client acknowledges they understand and provide their consent voluntarily

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    807 views0 pages

    IMM5743E

    Uploaded by

    Wuilmer B. Guerrero
    The document is a consent form for a client's immigration medical examination submitted to Citizenship and Immigration Canada (CIC). It contains the following key points: 1) The client declares that all medical information provided is true and consents to their medical results being collected and reported to CIC. 2) CIC may release the client's medical information to other government agencies in Canada and collect additional medical information about the client from agencies in Canada. 3) The client's information will be used to make a decision on their immigration application and may be used for future applications, and will be kept on file by CIC according to its privacy policies. 4) The client acknowledges they understand and provide their consent voluntarily

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    Citizenship and

    Immigration Canada
    Citoyennet et
    Immigration Canada
    PAGE 1 OF 1
    IMM 5743 (10-2012) E
    PROTECTED WHEN COMPLETED - B
    (AUSSI DISPONIBLE EN FRANAIS - IMM 5743 F)
    CLIENT CONSENT AND DECLARATION
    I, , declare that all information provided by me during my immigration medical
    examination in support of my application to Citizenship and Immigration Canada (CIC) is true, correct and complete. I have
    reviewed the medical history information provided by me and declare it is true, correct and complete.

    I give my consent and authorization for the panel physician, radiologist, and health workers or hospital to collect and report the
    results of my immigration medical examination to CIC.

    I understand that CIC:
    may release the information collected related to my immigration medical examination to, and
    may collect medical information about me from a federal, provincial or territorial public health or social service agency in
    Canada, or a physician or health worker in Canada for purposes related to the administration of Canada's Immigration and
    Refugee Protection Act or to protect the health and safety of Canadians and
    will use and disclose my information in a manner that is consistent with Canadian privacy law applicable to CIC.

    This information is provided in support of my application to CIC and 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 my application for the purpose of the administration of the Act. The
    information will be retained in the Personal Information Banks of CIC being CIC PPU 051, CIC PPU 054, or CIC PPU 055,
    depending upon the type of application made, as well as in CIC APB 012, CIC PPU 042 and CIC PPU 051.

    I, , have read and understand this notice and consent. I provide my consent
    voluntarily by signing this form.

    I understand that misrepresentation by an applicant providing false or misleading information is an offence under section 127
    of Canada's Immigration and Refugee Protection Act and may result in a finding of inadmissibility to Canada or removal from
    Canada.
    CLIENT CONSENT - (client 16 years and over)
    Client's family name Client's given name(s)
    Date (YYYY-MM-DD) Signature of client
    Date of birth (YYYY-MM-DD)
    DECLARATION OF PARENT/GUARDIAN - (client under 16 years of age)
    This declaration was made on behalf of by: Name of parent/guardian
    Date (YYYY-MM-DD) Signature of parent/guardian

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