Application For Criminal Rehabilitation - Citizenship And Immigration Canada Page 2

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Explain the purpose of your visit or stay in Canada

On a separate sheet of paper, provide reasons why you consider yourself to be rehabilitated and why you do not represent a risk to public safety.

Indicate #18: Rehabilitation Factor on the sheet of paper.

19 Addresses since the age of 18. (Use a separate sheet if necessary)

Forms will be returned if there is any period of time for which you have not shown an address. Do not use post office (P.O.) box addresses.

DATES

NUMBER AND STREET

APT.

PROVINCE / STATE

FROM

CITY OR TOWN

(Do not use P.O. boxes)

NO.

COUNTRY

(YYYY-MM)

Provide the details of your employment history since the age of 18. Start with the most recent information. Under "OCCUPATION", 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, traveling, 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.

DATES

NAME AND ADDRESS OF COMPANY

FROM

OCCUPATION

(Write name in full, do not use abbreviations)

(YYYY-MM)

THE INFORMATION YOU PROVIDE IN THIS DOCUMENT IS COLLECTED UNDER THE AUTHORITY OF THE CANADA IMMIGRATION AND REFUGEE

PROCTECTION ACT AND IS STORED IN PERONAL INFORMATION BANK NUMBER CIC PPU 042, 054 OR 300. THE INFORMATION IS PROTECTED

UNDER THE PROVISIONS OF THE PRIVACY ACT AND IS ACCESSIBLE TO YOU UPON REQUEST.