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Save to Officio Citizenship and Immigration Canada Citoyennete et Immigration Canada PROTECTED WHEN COMPLETED – B PAGE 1 OF 4 SCHEDULE A 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)? ) been refused refugee status, an immigrant or permanent resident visa (including a Certificat de selection du Quebec (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 Tito Given name(s) Roderick 2. Your full name written in your native language or script (e. . , Arabic, Cyrillic, Chinese, Korean, Japanese characters or Chinese commercial/telegraphic code) Roderick M. Tito 3.
4. Your date of birth Year Month Day 1972 01 17 Personal details of your father Family name Tito Given name(s) Felix 1 9 1 2 1 2 0 8 Danao City, Cebu Philippines 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? ) 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? Tito 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 Year Month Day 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 FRANCAIS – IMM 5669 F) Save to Officio 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 6 4 1.
5 Give full details of all the secondary and post secondary education (including university, college and apprenticeship training) you have had.
From To Type of certificate or Name of institution City and country diploma issued Y M M Y 2 0 1 1 1 1 2 0 1 2 0 3 2 0 1 2 0 3 2 0 1 2 0 3 1 9 9 7 1 2 1 9 9 7 1 2 1 9 9 7 0 6 1 9 9 7 0 7 BMC Training Center for Welding and Fabrication Inc. BMC Training Center for Welding and Fabrication Inc. MIAP Training and Service Center / TESDA Region VII Technical Education and Skills Development Authority ( TESDA Region VII ) Mandaue Technical Institute Mabolo Cebu City, Philippines Mabolo Cebu City, Philippines Cebu City, Philippines Cebu City, Philippines 1 9 9 4 0 6 1 9 9 5 0 4 8. Personal history
Mandaue City, Cebu Philippines Shielded Metal Arc Welding NC II ( 360 hrs.
) Industrial Pipefitting NC II ( 160 hrs. ) Industrial Pipefitting Course ( 80 hrs. ) Refrigeration and Air Conditioning 10 months Basic Seaman Course Provide the details of your personal history since the age of 18, or the past 10 years, whichever comes first. Start with the most recent information. Under “Activity”, write your occupation or job title if you were working. If you were not working, provide information on what you were doing (for example: unemployed, studying, travelling, retired, in detention, etc.
).
Note: Please ensure that you do not leave any gaps in time. Failure to account for all time periods will result in a delay in the processing of your application. From Y M Y To M Activity Welding Instructor and Aircon Techinician City or town and country Cebu City, Philippines Name of company, employer, school, facility, as applicable Brilliant Metal Craft Training Center for Welding and Fabrication Inc. 2 0 1 2 0 6 2 0 1 2 12 2 0 1 0 12 2 0 1 2 0 3 Electromechanical Supervisor Servicing Department Supervisor Machinist / Tool keeper Machinist / Fitter Mandaue City, Philippines Mandaue City, Philippines
MEPZ- I ,Mactan Island, Cebu, Philippines MEPZ- I ,Mactan Island, Cebu, Philippines ZERCOOL POWER Airconditioning and Electrical Services B and A TRADING and Airconditioning Services ABTECH Machineries and Engineering Services Corp.
ATA Engineering and Technology Consortium Inc. 1 9 9 7 0 6 2 0 1 0 12 1 9 9 4 0 4 1 9 9 6 12 1 9 9 2 1 1 1 9 9 4 0 3 9. Membership or association with organizations What organizations have you supported, been a member of or been associated with? Include any political, social, youth or student organization, trade unions and professional associations. Do not use abbreviations.
Indicate the city and country where you were a member.
Write “NONE” in the box if you have not been a member of any association/organization. From Y M Y To M Name of organization Insovilla Plains Homeowners Association BMC Assistant Instructor NONE Type of organization SOCIAL STUDENT Activities and/or positions held within organization PRESIDENT PRESIDENT City and country Lapu-lapu City, Cebu Philippines Cebu City, Philippines 2 0 0 7 0 3 2 0 1 2 2 0 1 2 0 5 2 0 1 2 0 6 NONE NONE 10. Government positions List any government positions (such as civil servant, judge, police officer) you have held. Do not use abbreviations.
Write “NONE” in the box if you have not held any government position.
From Y M Y To M Country and level of jurisdiction (e. g. national, regional, municipal) NONE Department/Branch Activities and/or positions held NONE NONE NONE NONE IMM 5669 (07-2011) E Save to Officio PAGE 3 OF 4 11. Military service Provide below details of military service for each of the countries in whose armed forces you served. Write “NONE” in the box if you have not undertaken military service.
Name of country NONE From Y M Y To M Branch of service, unit numbers and names of your commanding officers Rank(s) Dates and places of any active combat
NONE NONE NONE NONE NONE NONE Name of country NONE From Y M Y To M Branch of service, unit numbers and names of your commanding officers Rank(s) Dates and places of any active combat NONE NONE NONE NONE NONE NONE 12. Addresses List all addresses where you have lived since your 18th birthday. Do not use P. O. box addresses.
From Y M Y To M Juan Luna Street 749 M. L Quezon St. Cabancalan Insovilla Plains, Marigondon Street and number City or town Province, State or District Country 1 9 9 0 0 1 1 9 9 3 0 1 1 9 9 3 0 1 2 0 0 0 0 3 Danao City Mandaue CIty Lapu-lapu City Cebu Cebu Cebu Philippines Philippines Philippines 0 0 0 0 3 2 0 1 2 12 IMM 5669 (07-2011) E Save to Officio PAGE 4 OF 4 Authority to disclose personal information By submitting this form, you consent to the release to Canadian government authorities of all records and information any government authority, including police, judicial and state authorities in all countries in which you have lived may possess on your behalf concerning any investigations, arrests, charges, trials, convictions and sentences. This information will be used to assist in evaluating your suitability for admission to Canada or remaining in Canada pursuant to Canadian legislation.
Declaration of applicant I declare that the information I have given is truthful, complete and correct. Year Month Day Signature Date DO NOT COMPLETE THE FOLLOWING SECTION NOW.
YOU MAY BE ASKED TO SIGN IN THE PRESENCE OF A REPRESENTATIVE OF THE CANADIAN GOVERNMENT OR AN OFFICIAL APPOINTED BY THE CANADIAN GOVERNMENT. Solemn declaration I, , do solemnly declare that the information I have given in the foregoing application is truthful, complete and correct, and I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath.
Interpreter declaration I, , do solemnly declare that I have faithfully and accurately interpreted in the language the content of this application and any related forms to the person concerned. I have been informed by the person concerned, and I do verily believe, that he or she completely understands the nature and effect of these forms, and I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as is made under oath. Signature of applicant Signature of interpreter
Declared before me at Canadian Government official this day of of the year Name Please print or type Signature The information you provide on this form is collected under the authority of the Immigration and Refugee Protection Act and will be used for the purpose of assessing your application for permanent residence.
It will be stored in Personal Information Banks (PPU 039 entitled Overseas Immigration Case File and PPU 042 entitled Immigrant Case File). It may be shared with other organizations in accordance with the consistent use of information under the Privacy Act.
Under the provisions of 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 the Infosource website (http://infosource. gc.
ca) and are also available at public libraries across Canada. IMM 5669 (07-2011) E Family Name: Tito Save to Officio Given Name: Roderick . 7. Education Give the number of years of school you successfully completed for each of the following levels of education. Elementary/ Secondary/ University/ 6 4 primary school high school college
ADDENDUM 1.
5 Trade school or other post secondary school Give full details of all the secondary and post secondary education (including university, college and apprenticeship training) you have had. From Y M Y To M Name of institution BMC Training Center for Welding and Fabrication Inc. City and country Mabolo Cebu City, Philippines Mabolo Cebu City, Philippines Cebu City, Philippines Cebu City, Philippines Type of certificate or diploma issued Shielded Metal Arc Welding NC II ( 360 hrs. ) Industrial Pipefitting NC II ( 160 hrs. ) Industrial Pipefitting Course ( 80 hrs.
Refrigeration and Air Conditioning 10 months Basic Seaman Course 2 0 1 1 1 1 2 0 1 2 0 3 2 0 1 2 0 3 2 0 1 2 0 3 1 9 9 7 12 1 9 9 7 12 1 9 9 7 0 6 1 9 9 7 0 7 BMC Training Center for Welding and Fabrication Inc. MIAP Training and Service Center / TESDA Region VII Technical Education and Skills Development Authority ( TESDA Region VII ) Mandaue Technical Institute 1 9 9 4 0 6 1 9 9 5 0 4 . 8. Personal history Mandaue City, Cebu Philippines Provide the details of your personal history since the age of 18, or the past 10 years, whichever comes first. Start with the most recent information.
Under “Activity”, write your occupation or job title if you were working.
If you were not working, provide information on what you were doing (for example: unemployed, studying, travelling, in detention, etc. ). Note: Please ensure that you do not leave any gaps in time. Failure to account for all time periods will result in a delay in the processing of your application. From Y M Y To M Activity Welding Instructor and Aircon Techinician City or town and country Cebu City, Philippines Name of company, employer, school, facility, as applicable Brilliant Metal Craft Training Center for Welding and Fabrication Inc. 0 1 2 0 6 2 0 1 2 12 2 0 1 0 12 2 0 1 2 0 3 Electromechanical Supervisor Servicing Department Supervisor Machinist / Tool keeper Machinist / Fitter Mandaue City, Philippines Mandaue City, Philippines MEPZ- I ,Mactan Island, Cebu, Philippines MEPZ- I ,Mactan Island, Cebu, Philippines Mandaue City, Philippines Danao City, Philippines ZERCOOL POWER Airconditioning and Electrical Services B and A TRADING and Airconditioning Services ABTECH Machineries and Engineering Services Corp.
ATA Engineering and Technology Consortium Inc. 1 9 9 7 0 6 2 0 1 0 12 1 9 9 4 0 4 1 9 9 6 12 1 9 9 2 1 1 1 9 9 4 0 3 9 9 2 1 1 1 9 9 3 0 5 1 9 9 0 0 4 1 9 9 2 10 Production Worker Coal Miner Sunpride Foods, Inc. Almendras Mining Corporation 12. Addresses List all addresses where you have lived since your 18th birthday. Do not use P. O.
box addresses. From Y M Y To M Street and number City or town Province, State or District Country 1 9 9 0 0 1 1 9 9 3 0 1 1 9 9 3 0 1 2 0 0 0 0 3 Juan Luna Street Danao City Cebu Philippines 749 M. L Quezon St. Cabancalan Insovilla Plains, Marigondon Mandaue CIty Lapu-lapu City Cebu Cebu Philippines Philippines 2 0 0 0 0 3 2 0 1 2 12 IMM 5669 (07-2011) E .
