Citizenship and Immigration Canada
Citoyenneté et Immigration Canada
PROTECTED WHEN COMPLETED - B
PAGE 1 OF 4
BACKGROUND / DECLARATION
The principal applicant, his or her spouse or common-law partner, if applicable, and all dependent children aged 18 years or older listed in the application for permanent residence must complete their own copy of this form. If there is not enough space to provide all the necessary information, attach to this form a separate sheet of paper with further details. Print your name at the top of each additional sheet and indicate the form's title and the number of the question you are answering.
Before you start completing this form, make enough photocopies for your needs. You can also print all or part of this form from our Web site at www.cic.gc.ca. BEFORE YOU START, READ THE INSTRUCTION GUIDE TYPE or PRINT in black ink Indicate whether you are The principal applicant 1. Your full name Family name The spouse, common-law partner or dependent child aged 18 years or older of the principal applicant 6. Have you, or, if you are the principal applicant, any of your family members listed in your application for permanent residence in Canada, ever: YES NO a) been convicted of a crime or offence in Canada for which a pardon has not been granted under the Criminal Records Act of Canada? b) been convicted of, or are you currently charged with, on trial for, or party to a crime or offence, or subject of any criminal proceedings in any other country? c) made previous claims for refugee protection in Canada or at a Canadian visa office abroad, in any other country or countries, or with the United Nations High Commissioner for Refugees (UNHCR)? d) been refused refugee status, an immigrant or permanent resident visa (including a Certificat de sélection du Québec (CSQ) or application to the Provincial Nominee Program) or visitor or temporary resident visa, to Canada or any other country? e) been refused admission to, or ordered to leave, Canada or any other country? f) been involved in an act of genocide, a war crime or in the commission of a crime against humanity? Date of birth Town/City of birth Country of birth Date of death, if deceased 5. Year Month Day
Given name(s) Roderick
Your full name written in your native language or script (e.g., Arabic, Cyrillic, Chinese, Korean, Japanese characters or Chinese commercial/telegraphic code)
Roderick M. Tito
3. 4. Your date of birth
Year Month Day
Personal details of your father Family name
Given name(s) Felix
1 9 1 2 1 2 0 8
Danao City, Cebu
Year Month Day
g) used, planned or advocated the use of armed struggle or violence to reach political, religious or social objectives? h) been associated with a group that used, uses, advocated or advocates the use of armed struggle or violence to reach political, religious or social objectives? i) been member of an organization that is or was engaged in an activity that is part of a pattern of criminal activity? j) been detained, incarcerated or put in jail?
1 9 9 8
Personal details of your mother Family name at birth
k) had any serious disease or physical or mental disorder?
If your answer to any of these questions is YES, provide details below.
Given name(s) Fedilinda
Date of birth Town/City of birth Country of birth Date of death, if deceased
1 9 4 7 0 4 2 7
Danao City, Cebu Philippines
Year Month Day
This form is made available by Citizenship and Immigration Canada and is not to be sold to applicants. IMM 5669 (07-2011) E
(DISPONIBLE EN FRANÇAIS - IMM 5669 F)
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PAGE 2 OF 4 7. Education Give the number of years of school you successfully completed for each of the following levels of education. Elementary/ primary school Secondary/ high school University/ college Trade school or other post secondary school