Adult Simplified Renewal Passport Application Form
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5Read Instructions
PROTECTED WHEN COMPLETED - B
Simplified Renewal
Adult
Passport Application
for eligible Canadians applying in Canada or from the USA
Warning: Any false or misleading statement with respect to this application and any supporting document, including
the concealment of any material fact, may result in the refusal to issue a passport, the revocation of a currently valid
passport, or the refusal of passport services, and may be grounds for criminal prosecution. Your application will not be
processed if you fail to complete all of the required sections of this form and/or refuse to consent to the exchange or
disclosure of any personal information required for the delivery of passport services.
Type or print in CAPITAL LETTERS using black or dark blue ink.
1
Personal Information (see Instructions, section H)
Surname (last name)
Given name(s)
Date of travel
Month
Day
Surname (last name) at birth
Unknown
Former surname (last name)
Mother's maiden name
Date of birth
Place of birth
Year
Month
Day
City
Country
Prov./Terr./State (if applicable)
Sex
Height (cm/in)
Weight (kg/lbs)
Marital status
Eye colour
Current hair colour
Female
Male
Current home address
Number
Street
Apartment
City
Province/Territory/State
Postal/ZIP code
Mailing address (if different from current home address)
Number
Street
Apartment
City
Province/Territory/State
Postal/ZIP code
Telephone (other)
Cell number or email address (optional)
Telephone (daytime)
Declaration—I solemnly declare that I am a Canadian citizen, that the
Sign within border
photos enclosed are unaltered and a true likeness of me, that all of the
statements made and the information provided in this application, as well
as any supporting documents, are true. I declare that I have read and
understood the Warning at the top of this page and the Privacy Notice
Statement (see section J). I consent to the collection, use and disclosure
of my personal information by the Passport Program, Immigration,
Signature (see Instructions, section H)
Refugees and Citizenship Canada, other federal government institutions,
Government of Canada offices abroad and third party entities as outlined
Date
Signed at
in the Privacy Notice Statement in the Instructions.
Year
Month
Day
Province/Territory/State
City
2
Previous Canadian Passport (see Instructions, section I)
Date of issue
Date of expiry
Enclose any Canadian passport issued to you
Passport number
Year
Month
Day
Year
Month
Day
within the last six (6) years.
If you cannot submit the previous passport, or if the previous passport is damaged, you cannot use this form.
Would you like the previous passport returned to you? If not, it will be securely destroyed by the Passport Program to protect your
personal information.
Yes, please return it to me.
3
Canadian Citizenship
To be completed if you were born outside of Canada between February 15, 1977 and April 16, 1981 inclusive.
a) Are you a naturalized Canadian, i.e. did you receive
Yes – Go to page 2
No – Continue to question b)
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).
Complete and submit form PPTC 001, Proof of Canadian Citizenship—Additional Information,
Before January 1, 2007
available online at Canada.ca/passport.
Aussi accessible en français - PPTC 055
- Page 1 of 5
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