Adult Simplified Renewal Passport Application For Canadians Applying In Canada Or From The Usa Page 6

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4
Additional Personal Information
Note: If insufficient space, attach a separate sheet.
A Addresses in the last two (2) years
Same as current address.
Addresses in the last two (2) years if different from current address.
(Number, Street, Apartment, City, Province/Territory/State, Country)
From
To
Year
Month
Year
Month
1.
From
To
Year
Month
Year
Month
2.
B Occupation in the last two (2) years
(if you are a homemaker or retired, indicate this in the “Employer/school or other” column).
In the last two (2) years,
my employers were and/or
I was attending educational institutions as follows:
Employer/school or other
Address
Daytime telephone
Field of employment/studies
Date (from)
Date (to)
5
References
Provide the following information with respect to two (2) persons who are not your relatives and have known you for at least two (2)
years. They may be contacted to confirm your identity.
1. Surname (last name)
Given name(s)
Relationship
Address
(Number, Street, Apartment, City, Province/Territory/State, Country)
Daytime telephone number Evening telephone number
Cell number or email address
Has known me for
(optional)
State number of years
2. Surname (last name)
Given name(s)
Relationship
Address
(Number, Street, Apartment, City, Province/Territory/State, Country)
Daytime telephone number Evening telephone number
Cell number or email address
Has known me for
(optional)
State number of years
6
Emergency Contact
(optional)
We recommend that you provide the name of someone who would not normally travel with you. This information is helpful if
you have an accident or become ill while travelling outside of Canada.
Surname (last name)
Given name(s)
Relationship to applicant
Daytime telephone number
Evening telephone number
Cell number
Address
Number
Street
Apartment
City
Prov./Ter./State
Postal/Zip code
7
Declaration of Applicant
DECLARATION—I solemnly declare that the statements made in this application are true.
Signature of applicant
Date
Signed at
Year
Month
Day
City
Province/Territory/State
The Fees and Credit Card Information
(see General Information, sections C and D)
To obtain the most recent version of this form, visit our website at
PPTC 054 (2011-11) R1
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