(DISPONIBLE EN FRANÇAIS - PPTC 056 F)

PROTECTED WHEN COMPLETED - B

Page of

ADDITIONAL INFORMATION ADDRESS AND OCCUPATION

PPTC 056 (01-2019) E

File number:

WARNING—Any false or misleading statement with respect to this form 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.Note: If insufficient space, attach a separate signed and dated sheet.

APPLICANT'S PERSONAL INFORMATIONSurname (last name) Given name(s) Date of birth (YYYY-MM-DD)

ADDRESS(ES)Address(es) in the last two (2) years

(Number, Street, Apartment, City, Province/Territory/State, Country, Postal/ZIP Code)

From

YYYY MM

To

YYYY MM

(Number, Street, Apartment, City, Province/Territory/State, Country, Postal/ZIP Code)

From

YYYY MM

To

YYYY MM

From

YYYY MM

To

YYYY MM(Number, Street, Apartment, City, Province/Territory/State, Country, Postal/ZIP Code)

OCCUPATION(S)Provide your occupation(s) during the last two (2) years. Check all that apply.

I am/was in school (full or part-time) and/or

I am/was employed (full or part-time) and/or

Other form of occupation (e.g. homemaker, retired, unemployed).

Enter the details for the occupation(s) you had during the last two (2) years as follows:

Employer/school or other Address Daytime telephone number

Field of employment/studies Date (from) (YYYY-MM)

Date (to) (YYYY-MM)

Please specify:

DECLARATION OF APPLICANTDECLARATION—I solemnly declare that I am a Canadian citizen and that all of the statements made and the information provided in this form, 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 listed in the Instructions for the passport application form to which this form relates (see section N). I consent to the collection, use and disclosure of my personal information by the Passport Program, Immigration, Refugees and Citizenship Canada, other federal government institutions, Government of Canada offices abroad and third party entities as outlined in the Privacy Notice Statement.

Signature of applicant Date (YYYY-MM-DD)

Signed at

City Country