Citizenship and
Immigration Canada		 Citoyenneté et
Immigration Canada		 PROTECTED WHEN COMPLETED - B
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IMM 5710 (07-2012) E This form is made available by Citizenship and Immigration Canada and is not to be sold to applicants.
(DISPONIBLE EN FRANÇAIS - IMM 5710 F)

APPLICATION TO CHANGE CONDITIONS,
EXTEND MY STAY OR REMAIN IN CANADA AS A WORKER




1   UCI 2   I want service in
OFFICE USE ONLY
Validated
NO
3   I am applying for one or more of the following:
A work permit with the same employer A work permit with a new employer
Restoration of temporary resident status as a worker Initial temporary resident permit or extension of temporary resident permit

PERSONAL DETAILS
1 Full name
Family name (as shown on your passport or travel document)

Given name(s) (as shown on your passport or travel document)

2 Have you ever used any other name (e.g. Nickname,maiden name,alias,etc.)?
   No     Yes
Family name

Given name(s)

3 Sex 4 Date of birth 5 Place of birth



YYYYY        MM      DD

 City/Town
Country
6 Citizenship
7 Current country of residence:
Country Status Other From To


YYYY-MM-DD

YYYY-MM-DD
8 Previous countries of residence: During the past five years have you lived in any country other than your country of citizenship or your current
  country of residence (indicated above) for more than siz months? 		      No     Yes
Country Status Other From To


YYYY-MM-DD

YYYY-MM-DD


YYYY-MM-DD

YYYY-MM-DD
9 Current where applying:    Same as current country of residence?    No     Yes
Country Status Other From To


YYYY-MM-DD

YYYY-MM-DD
10 a)Your current marital status b) (If you are married or in a comon-law relationship) Provide the date
on which you were married or entered into the common-law relationship 		Date

YYYY-MM-DD
   
   c)Provide the of your current Spouse/Common-law partner
   Family name


Given name(s)

FOR OFFICE USE ONLY - DO NOT WRITE IN THIS SPACE
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IMM 5710 (07-2012) E
  Applicat Name

  , . 		Date of Birth

PERSONAL DETAILS(CONTINUED)
11 Have you previously been married or in a common-law relationship?    No     Yes
   Provide the following details for your previous Spouse/Common-law Partner:
   Family name

   
Given name(s)
Type of relationship

From


YYYY-MM-DD 		To


YYYY-MM-DD

LANGUAGE(S)
1 a) Native language b) If your native language is not English or French, which language do you use most frequently?

PASSPORT
1 Passport number 2 Country of issue 3 Issue date 4 Expiry date

CONTACT INFORMATION
1 Current mailing address
- All correspondence will go to this address unless you indicate your e-mail address below.
- Indicating an e-mail address will authorize all correspondence, including file and personal information, to be sent to the e-mail address you specify.
- If you wish to authorize the release of information from your application to a representative, indicate their e-mail and mailing address(es) in this section and on the IMM5476 form.
P.O.box Apt/Unit Street no. Street name
City/Town Country Province/State Postal code District
2 Residential address    Same as mailing address?    No     Yes
Apt/Unit Street no. Street Name City/Town
Country Province/State Postal code District
3 Telephone no.    Canada/US     Other 4 ALTERNATE Telephone no.    Canada/US     Other
   Type Country code No. Ext.    Type Country code No. Ext.
   ( )        ( )    
5 Fax no. 6 E-mail address
   Canada/US Country code No. Ext.
   Other ( )    

DETAILS OF INTENDED WORK IN CANADA
1 What type of work permit are you applying for?
2 Details of my prospective employer (attach original offer of employment)
a) Name of Employer (If you are employed by a foreign employer who has been awarded a contract to provide services to a Canadian entity, please identify the foreign employer here)
b) Complete Address of Employer (Canadian of Foreign):
3 Intended location of employment in Canada?
Province
 City/Town
 Address
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IMM 5710 (07-2012) E
  Applicat Name

  , . 		Date of Birth

DETAILS OF INTENDED WORK IN CANADA (CONTINUED)
4 My occupation in Canada will be: Brief description of duties
Job title

5 From To 6 Labour market opinion (LMO) No.
Duration of expected
employment
YYYY-MM-DD
YYYY-MM-DD

LIVE-IN CAREGIVER PROGRAM
1 Type of care, indicate all that apply: 2 No, of persons requiring care
   Child cared     Disabled Elderly Other

EDUCATION
Have you had any post secondary education (including university, college or apprenticeship training)?

If you answered "yes", give full details of your highest level of post secondary education. 		   No     Yes
1 From



YYYY MM		 Field of study

 School/Facility name
To



YYYY MM		 City/Town
Country
Province

EMPLOYMENT
Give details of your employment for the past 10 years. If retired, not working, or studying, please indicate. If you are retired, provide the 10 years before your retirement.
1 From



YYYY MM		 Current Activity/Occupation

 Company/Employer/Facility name
To



YYYY MM		 City/Town
Country
Province/State
2 From



YYYY MM		 Current Activity/Occupation

 Company/Employer/Facility name
To



YYYY MM		 City/Town
Country
Province/State
3 From



YYYY MM		 Current Activity/Occupation

 Company/Employer/Facility name
To



YYYY MM		 City/Town
Country
Province/State

BACKGROUND INFORMATION
You must complete this section if you are 18 years of age or older.
1 a) Within the past tow years, have you or a family member ever had tuberculosis of the lungs or been in close contact with a person with tuberculosis?    No     Yes
b) Do you have any physical or mental disorder that would require social and/or health services, other than medication, during a stay in Canada?    No     Yes
c) If you answered "yes" to question 1a) or 1b), please provide details and the name of the family member (if applicable).


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IMM 5710 (07-2012) E
  Applicat Name

  , . 		Date of Birth

BACKGROUND INFORMATION (CONTINUED)
2 a) Have you ever previously applied for any Canadian visas (For example: Permanent Resident, Temporary Resident(Visitor, Student, Worker),
   Temporary Resident Permit)? 		   No     Yes
b) Have you ever been refused any kind of visa to travel to Canada?    No     Yes
c) Have you ever been refused admission or been ordered to leave Canada or any other country?    No     Yes
d) If you answered "yes" to question 2a), 2b), or 2c) please provide details.


3 Have you ever committed, been arrested for, been charged with or convicted of any criminal offence in any country?    No     Yes
4 a) Have you ever been in a military, militia or civil defence unit or the police?    No     Yes
b) If you answered "yes" to question 4a), please provide dates of service and countries where you served.


5 Have you ever been employed by a govermment in a security-related capacity?    No     Yes
6 Have you ever held a position of authority in any goverment, or judiciary or a political party?    No     Yes
7 Have you ever in periods of either peace or war, been involved in the commission of a war crime against humanity, such as:
willful killing, torture, attacks upon, enslavement, starvation or other inhumane acts committed civilians or prisoners of war, or deportation of civilians? 		   No     Yes

I consent to the release to Citizenship and Immigration Canada(CIC) and Canada Border Services Agency (CBSA) of all records and information for the purpose of processing my request
that any government authority, including police, judicial and state authorities in all countries in which I have lived may possess about me. This information will be used to evaluate my
suitability for admission to Canada or to remain in Canada pursuant to Canadian legislation.

I declare that I have answered all questions in this application fully and truthfully.


Signature of Applicant or Parent/Legal Guardian's for a person under 18 years of age. Date:YYYY-MM-DD

IMPORTANT NOTE:
This application must be signed and dated before it is submitted.
   Do not forget to include: photos, fees (if applicable), and any other documents required by the visa office.

The information you provide on this form is collected under the authority of the Immigration and Refugee Protection Act to determine if you may be admitted to Canada as a visitor. It will be stored in Personal Information Bank
CIC PPU 054, Visitor Case file. The information may be shared with other organizations such as the Canada Border Services Agency (CBSA), the Royal Canadian Mounted Police (RCMP), the Canadian Security Intelligence Service
(CSIS) and foreign governments in accordance with the subsection 8(2) of ther Privacy Act. In accordance with the Privacy Act and the Access to Information Act individuals have a right to protection of and access to their personal
information. Details on these matters are available at the Infosource website (http://infosource.gc.ca) and through the Citizenship and Immigration Canada Call Centre. Infosource is also available at public libraries across
Canada.