Adult Simplified Renewal Passport Application For Canadians Applying In Canada Or From The Usa Page 5
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INFORMATION
Adult SIMPLIFIED RENEWAL Passport Application
PROTECTED
for Canadians applying in Canada or from the USA
WARNING to all applicants—Any false or misleading statement on this form or relating to any document in support of this
application, including concealment of any material fact, may lead to refusal to issue or revocation of a passport and be
grounds for criminal prosecution.
Failure to complete all the required sections of this form will result in your application being refused.
PRINT OR TYPE IN CAPITAL LETTERS using black or dark blue ink.
1
Personal Information (see Instructions, section J)
Surname (last name)
Given name(s)
Date of travel
Month
Day
Surname (last name) at birth
Unknown
Former surname (former last name)
Mother's maiden name
Date of birth
Place of birth
Year
Month
Day
City
Country
Prov./Ter./State (if applicable)
Sex
Marital status
Eye colour
Current hair colour
Height
Weight
Female
Male
Current home address
Number
Street
Apartment
City
Prov./Ter./State
Postal/Zip code
Mailing address
(if different from above)
Number
Street
Apartment
City
Prov./Ter./State
Postal/Zip code
Evening telephone number
Cell number or email address
Daytime telephone number
(optional)
DECLARATION—I solemnly declare that I am a Canadian citizen, that the
Void if signature touches border
photos enclosed are a true likeness of me and that all of the statements made
in this application are true. I declare that I have read and understood the
WARNING to all applicants at the top of this page.
Date
Signed at
Year
Month
Day
Signature (see Instructions, section J)
Province/Territory/State
City
2
Previous Canadian Travel Document (see Instructions, section K)
Enclose any Canadian passport issued to you within the last six (6) years from the date we receive this application.
If you cannot submit the previous passport, you cannot use this form.
3
Canadian Citizenship
To be completed if you were born outside of Canada between February 15, 1977 and April 16, 1981 inclusively.
Yes – Go to page 2
No – Continue to question b)
a) Are you a naturalized Canadian?
(i.e. did you receive
Canadian citizenship following immigration to Canada?)
b) Was one of your parents born in Canada?
Yes – Go to page 2
No – Continue to question c)
c) When was your current certificate of Canadian citizenship issued?
After January 1, 2007
Submit the certificate with your application (original only).
Before January 1, 2007
Complete and submit form PPTC 001, Proof of Canadian Citizenship–Additional Information,
available at or at any Passport Canada regional office,
participating Canada Post office, participating Service Canada Centre in Canada or
Government of Canada office in the USA.
Aussi disponible en français
PPTC 054 (2011-11) R1
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