PROTECTED WHEN COMPLETED - B

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APPLICATION FOR A PERMANENT RESIDENT CARD

UCI number

Confused by a question? See step 2 of the instruction guide.

TYPE or PRINT in black or blue ink
(YYYY-MM-DD)
1. Language you prefer for correspondence English French 2. Date you became a permanent resident of Canada
Obtain your first Renew your present Replace a lost, stolen, destroyed or never
3. You are applying to (check one box) Permanent Resident Card Permanent Resident Card received Permanent Resident Card

NOTE: If you are applying to renew your present card, you should keep it until you receive your replacement card. You will be asked to destroy your old card when you receive your
new one. If you are applying to replace your damaged card, you must send the damaged card with your application.

A. PERSONAL DETAILS

4. Your full name as shown on your Record of Landing (IMM 1000), Confirmation of Permanent Residence (IMM 5292) or (IMM 5688), or last Permanent Resident Card (include a
photocopy of your last Permanent Resident Card).

Family name (surname) Given name(s)

5. Your current name, if different from above

(Note: you must provide supporting documents for any change in your name. Consult "Legal Name Change" in the instruction guide
Family name (surname) Given name(s)

(YYYY-MM-DD)
6. Your sex Male Female 7. Your date of birth 8. Your country of birth

9. Your country or countries of citizenship

10. Colour of your eyes Blue Grey Brown Green Black Hazel (yellowish brown) Other
11. Your height cm or ft in
12. Your current residential address in Canada
Apartment Street no. Street name

City Province Postal code

13. Your mailing address in Canada (if different from above)

Apartment Street no. Street name

City Province Postal code

All correspondence will go to this address unless you indicate your e-mail address below. Indicating an e-mail address will authorize all correspondence, including file and personal
information, to be sent to the e-mail address you specify.

14. Your telephone numbers and e-mail address

At home Alternative E-mail

15. Your current marital status

Never married Married Widowed Legally separated Divorced Common-law

B. YOUR IMMIGRATION HISTORY

16. Place you became a permanent resident of Canada

City/Port of entry Province

17. Have you ever been issued a removal order in Canada? Yes No

18. Has an Immigration Officer ever issued you a Report Under subsection 44(1) or made the decision Yes No
that you have not met the residency obligations required of Canadian permanent residents?

This form is made available by Immigration, Refugees and Citizenship Canada and is not to be sold to applicants.
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(DISPONIBLE EN FRANAIS - IMM 5444 F)
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C. PERSONAL HISTORY - If you need additional space for any of the questions below, print out an additional page containing the appropriate section, complete it and
submit it with your application.
19. ADDRESS HISTORY INSIDE AND OUTSIDE CANADA: Your address history for the past five (5) years or if you became a permanent resident less than five (5) years
ago, your address history since becoming a permanent resident. List ALL your addresses in chronological order from the oldest to the most recent.
From To
Apartment, street no. and street name City or town Province Country
(YYYY-MM-DD) (YYYY-MM-DD)

20. WORK AND EDUCATIONAL HISTORY INSIDE AND OUTSIDE CANADA: Your work and educational history for the past five (5) years or if you became a permanent
resident less than five (5) years ago, your work and/or educational history since becoming a permanent resident. If you have not worked or studied, provide your other
activity history, including location. List ALL your activities in chronological order from the oldest to the most recent.
From To Name of employer or name of educational institution
City or town Province Country
(YYYY-MM-DD) (YYYY-MM-DD) attended (do not use abbreviations)

21. TRAVEL HISTORY: Have you travelled or lived outside of Canada in the last five (5) years (or if you became a permanent resident less than five (5) years ago, since
becoming a permanent resident)? Include ALL absences (including those due to employment, vacations, trips to the United States and any other time you left Canada).

No Yes List all your absences: Period to be assessed:

From To
(YYYY-MM-DD) (YYYY-MM-DD)

From To
Your location during your absence (city, country) Reason for absence Number of days
(YYYY-MM-DD) (YYYY-MM-DD)

Total number of days

IMPORTANT: If your total number of days outside Canada is equal to 1095 days or more, you must complete Section D below.

D. RESIDENCY OBLIGATION TIME SPENT OUTSIDE CANADA

Complete this section if you have been outside of Canada for 1095 days or more in the past five (5) years.

22. List ALL your absences from Canada in the past five (5) years according to the situation that applies to you. If you became a permanent resident less than five (5) years
ago: list ALL absences from the time you became a permanent resident to present. List your absences in chronological order from the oldest to the most recent.

Situation 1 - Absences while accompanying a family member who is a Canadian citizen

Name of family member Provide proof of Canadian citizenship.

Relationship to you Provide proof of your relationship.

From To Total number

No. and street City/Town, country
(YYYY-MM-DD) (YYYY-MM-DD) of days

Total number of days

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D. RESIDENCY OBLIGATION TIME SPENT OUTSIDE CANADA (continued)

Situation 2 - Absences while employed by a Canadian business outside Canada or in the Canadian federal or provincial public service
Provide proof of full-time Canadian employment

From To Total number

No. and street City/Town, country
(YYYY-MM-DD) (YYYY-MM-DD) of days

Total number of days

Situation 3 - Absences while accompanying a family member who is a permanent resident of Canada AND who is employed by a Canadian business outside Canada
or in the Canadian federal or provincial public service

Provide proof of this person's permanent resident status and proof of this
Name of family member person's full time employment.

Relationship to you Provide proof of your relationship.

From To Total number

No. and street City/Town, country
(YYYY-MM-DD) (YYYY-MM-DD) of days

Total number of days

E. CONSENT TO DISCLOSE INFORMATION

23. History of entries into Canada

By selecting "YES" in the box below, and by signing this form, I hereby give my consent to the Canada Border Services Agency (CBSA) to disclose the details of my history of
entries into Canada to Immigration, Refugees and Citizenship Canada (IRCC) in order to assist IRCC in determining my eligibility for a permanent resident card.

I also hereby authorize IRCC to collect the history of my entries into Canada from the CBSA.

Yes No

Note that if you do not provide consent, you may be asked to request your history of entries directly from the CBSA and send it to IRCC which could result in delays in the
processing of your application.

F. STATEMENT OF CONSENT

24. Income tax information and filing history

By selecting "YES" in the box below, and by signing this application form, I hereby give my consent to the Immigration, Refugees and Citizenship Canada (IRCC) to collect my
Social Insurance Number (SIN) for the purpose of requesting that the Canada Revenue Agency (CRA) disclose my income tax information and residency information for any
taxation years required to assist the department in determining whether I meet the residency obligation as set out in Section 28 of the Immigration and Refugee Protection Act.

Yes No

Social Insurance Number (SIN)

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G. DECLARATION OF APPLICANT

25. This declaration covers the information that I have provided on this form and all the information submitted with my application for a Permanent Resident Card as well
as the attached accompanying documents.

I declare that the information I have given is truthful, complete and correct.
I understand that any false statements or concealment of a material fact may be grounds for my prosecution or removal.
The photographs enclosed are a true likeness of me.
I am a permanent resident of Canada.
I am not a Canadian citizen.
I understand all the foregoing statements, having asked for and obtained an explanation on every point that was not clear to me.
I realize that once this document has been completed and signed, it will form part of my Immigration Record and will be used to verify my family details on future applications.
I will immediately inform Immigration, Refugees and Citizenship Canada if any of the information or the answers provided in my application forms change.

SIGN SECTION G BEFORE PROCEEDING TO SECTION H.

To avoid processing delays, ensure your application is not postdated or stale dated.

Signature of parent
Signature
or legal guardian,
of declarant
if applicable
(YYYY-MM-DD) (YYYY-MM-DD)
Date Date

City I am the applicant's:

Mother Father Legal guardian
(check appropriate box)
Province

H. SOLEMN DECLARATION CONCERNING A LOST, STOLEN, DESTROYED OR NEVER RECEIVED PERMANENT RESIDENT CARD

26. Complete this section only if you are applying to replace a lost, stolen, destroyed or never received PR Card.

Date of issue (YYYY-MM-DD)

Permanent Resident Card number

Lost Stolen
My Permanent Resident Card was on or about
(YYYY-MM-DD)
at
Destroyed Never received

Under the following circumstances (full information must be provided below):

I have made the following efforts to locate this document

(if applicable, indicate police authorities notified and attach a copy of police report or incident report number):

Should I ever regain possession of my original PR Card, I promise to destroy it immediately.

I solemnly declare that the information I have provided is true, that is of the same force and effect as if made under oath, and that it was freely given. I authorize the department of
Immigration, Refugees and Citizenship Canada to verify the information I have provided. I also understand that the provision of any false or misleading information may lead to
prosecution in accordance with Section 127 of the Immigration and Refugee Protection Act.

DO NOT SIGN HERE UNLESS YOU ARE DECLARING A LOST, STOLEN, DESTROYED OR NEVER RECEIVED PERMANENT RESIDENT CARD.

Signature of parent
Signature
or legal guardian,
of declarant
if applicable
(YYYY-MM-DD) (YYYY-MM-DD)
Date Date

The information you provide on this form is collected under the authority of the Immigration and Refugee Protection Act and will be used to determine whether the term and conditions
of your permanent residency were maintained and whether you should be granted a Permanent Resident Card. It will be retained in the Personal Information Bank CIC PPU 067
entitled Permanent Resident Card as identified in infosource. It may be shared with other organizations in accordance with the consistent use of information under the Privacy Act.
Under 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
infosource.gc.ca. Infosource is also available at Public Libraries in Canada.

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