Sc Isp-3210 - Canadian Citizenship Application Form Page 2
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PROTECTED B (when completed)
Canada
Consent to Exchange Information with Citizenship
and Immigration Canada
PART A - CURRENT PERSONAL DETAILS
(Please note that all fields are mandatory. If you do not have the
information requested, please state “unknown” in the space provided.)
3. Sex
1. Current Surname
2. Current Given name(s)
Male
Female
4. Date of Birth (YYYY-MM-DD) 5. Place of Birth - City
Province / State
Country
6. Are you
Permanent Resident 7. Language of correspondence
Canadian Citizen
English
French
8. Mailing address
No.
Street Name
Apt. No.
P.O. Box
R.R.
City / Town or Village
Province / Territory
Country
Postal Code
9. Current Passport No.
10. Date of Issue (YYYY-MM-DD)
11. Expiry Date (YYYY-MM-DD)
PART B - DETAILS ON ENTRY
(Please note that all fields are mandatory. If you do not have the information
requested, please state “unknown” in the space provided.)
1. Citizenship & Immigration Canada Unique Client Identifier or Client ID number
2. Surname (Family name) on entry was
3. Given name(s) on entry
4. Marital status on entry
5. If you were married on entry, was your
spouse a Canadian citizen or permanent
Never Married
Married
Widowed
resident?
Separated
Divorced
Yes
No
Common-law partner
6. Passport number on Entry, if known 7. Date of Issue (YYYY-MM-DD) 8. Expiry Date (YYYY-MM-DD)
9. Date of Entry in Canada
10. a) Canadian port of entry
10. b) Immigration document - Place of Issue
(YYYY-MM-DD)
11. Did you enter Canada as a
Visitor
Student
Worker
Permanent Resident
Unknown
Other (specify)
Service Canada delivers Employment and Social Development Canada
programs and services for the Government of Canada.
SC ISP-3210 (2015-07-21) E
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