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Form Cit 0001 - Application For A Citizenship Certificate For Adults And Minors - Immigration, Refugees And Citizenship Canada Page 8

PAGE 7 OF 7

I agree to advise Immigration, Refugees and Citizenship Canada (IRCC) if any information on this form changes before the processing

of my application is complete. I understand the content of this form. I declare that the information provided is true, correct and complete,

and that the photographs enclosed are a true likeness of me. I understand that if I, or someone on my behalf, make a false

representation, commit fraud or conceal any material circumstances relevant to my application, my application could be denied, my

citizenship certificate could be taken away, and I could be charged with an offence as provided for under the Citizenship Act or the

Criminal Code.

Signature of applicant

(you must sign inside the white box in black ink only)

YYYY-MM-DD

City

Date

If applicant is under 14 years of age, signature of parent/guardian:

Signature of parent/guardian

(you must sign inside the white box in black ink only)

YYYY-MM-DD

City

Date

REMEMBER:

If you are sending more than one application, send all of them together in one envelope. The applications will be processed

together.

Protected Information

Personal Information Bank CIC PPU 050

The information you provided on the application is collected under the authority of the Citizenship Act and is required to determine whether your citizenship application may be

approved. The information will be retained in the Personal Information Bank CIC PPU 050 identified in Infosource. It may be shared with other organizations in accordance or disclosed,

without notice or consent, pursuant to the Citizenship Regulations and to subsection 8(2) of the Privacy Act. Under the Privacy Act and the Access to Information Act, individuals have

the right to protection of, access to and correction of their personal information. Details of these matters are available at Infosource.gc.ca, at , at the local IRCC offices

and at any Canadian public library.

CIT 0001 (04-2016) E