B
PROTECTED WHEN COMPLETED -
PAGE 1 OF 3
REQUEST TO AMEND THE RECORD OF LANDING (IMM 1000), CONFIRMATION OF PERMANENT
RESIDENCE (IMM 5292 or IMM 5688) OR VALID TEMPORARY RESIDENT DOCUMENTS
1
Client ID number/UCI
PART A - PERSONAL DETAILS CONTAINED ON YOUR IMM 1000, IMM 5292
OR IMM 5688, OR VALID TEMPORARY RESIDENT DOCUMENTS
3
2
Surname(s) (Family name) (As it currently appears on your document)
Given name(s) (As it currently appears on your document)
4
5
6
Other name(s) used
Other given name(s) used
Sex
Male
Female
7
8
Place of birth (City, state/province and country)
9
Citizenship
Date of birth
YYYY-MM-DD
10
Passport number
Indicate if:
On entry
Current
11
12
Date of
Expiry
issue
date
YYYY-MM-DD
YYYY-MM-DD
13
Marital status
If you are married, is your spouse a
Never married
Married
Yes
No
Canadian citizen or permanent resident?
Widowed
Separated
Divorced
Common-law partner
14
English
French
Language of correspondence
15
Current mailing address
P.O. box
Apt./Unit
Street no.
Street name
City/Town
Postal code
District
Country
Province/State
16
Residential address Same as mailing address?
No
Yes
Apt./Unit
Street no.
Street name
City/Town
Postal code
District
Country
Province/State
17
18
Telephone no.
Canada/US
Other
Alternate Telephone no.
Canada/US
Other
Country Code
No.
Ext.
Country Code
No.
Ext.
Type
Type
19
E-mail address: (Indicating an e-mail address will authorize all correspondence, including file and personal information, to be sent to the e-mail address you specify.)
20
21
Date permanent residence or
Date of original entry
temporary residence was granted
YYYY-MM-DD
YYYY-MM-DD
PART B - INFORMATION TO BE AMENDED
Please indicate for which of the following you need a correction. If you have more than one valid temporary resident document, indicate the document ID number or if
1
unknown, the document issue date and expiry date of the requested document.
Immigrant Visa and Record of Landing -
Exclusion Order
Departure Order
Confirmation of Permanent Residence
Permit to Come Into or Remain in Canada -
Authorization to Return to Canada
Protected Person
Temporary Resident Permit
OR
Issue date:
and
Expiry date:
Work Permit
ID No.:
(YYYY-MM-DD)
(YYYY-MM-DD)
OR
Issue date:
and
Expiry date:
Study Permit
ID No.:
(YYYY-MM-DD)
(YYYY-MM-DD)
OR
Issue date:
and
Expiry date:
Visitor Record
ID No.:
(YYYY-MM-DD)
(YYYY-MM-DD)
This form is made available by Citizenship and Immigration Canada and is not to be sold to applicants.
IMM 1436 (10-2015) E
(AUSSI DISPONIBLE EN FRANÇAIS - IMM 1436 F)
1
2
3
