E672 – CANPASS Application Form

Section B – Address history for the last five years

• 17. Current address since: (Year | Month)
• 18. Street address
• 19. Apt.
• 20. City
• 21. Province/State
• 22. Postal/Zip code
• 23. Country
• 24. Home telephone
• 25. Business telephone
• 26. Cellular telephone
• 27. Email address

Mailing address if different from residential address

• 28. Street address
• 29. Apt.
• 30. City
• 31. Province/State
• 32. Postal/Zip code
• 33. Country

Previous residential addresses if you have been at your current residence for less than five years (attach a separate sheet if necessary).

• 34. From: (Year /Month) To: (Year / Month)
• 35. Street address
• 36. Apt.
• 37. City
• 38. Province/State
• 39. Postal/Zip code
• 40. Country

Section C – Employment history for the last five years

• 41. Current employer since: (Year / Month)
• 42. Employer's name
• 43. Street address
• 44. City
• 45. Province/State
• 46. Postal/Zip code
• 47. Country
• 48. Telephone number and Ext.
• 49. If self-employed, please specify type of business:
• 50. Other (please specify)

Previous employer's name and addresses if you have been with your current employer for less than five years (attach a separate sheet if necessary).

• 51. From: (Year / Month) To: (Year / Month)
• 52. Employer's name
• 53. Street address
• 54. City
• 55. Province/State
• 56. Postal/Zip code
• 57. Country

Section D – This section must be completed by all non-Canadian citizens and all non-Canadian permanent residents

• 58. What is the purpose of your travel to Canada? (check all applicable boxes)
  • Pleasure
  • Business/Work
  • Study
  • Other (specify)
  • Expiry date

  Section E – Additional information

  • 59. Have you ever been:
    • found in violation of any customs legislation? (Yes/No)
    • found in violation of any immigration legislation? (Yes/No)
    • convicted of an offence for which a pardon or rehabilitation has not been granted? (Yes/No)
    • If you are a U.S. citizen permanent resident, do you have a Federal Bureau of Investigation (FBI) criminal history record? (Yes/No)

    Section F – Customs programs (complete if applicable)

    CANPASS Corporate Aircraft - Company information

    • 60. Company name
    • 61. Address
    • 62. City
    • 63. Province/State
    • 64. Postal/Zip code
    • 65. Mailing address (if different from above)
    • 66. Principal company contact (for renewals and administrative purposes)
      • Last name
      • First name
      • Mr./Mrs./Miss/Ms
      • Title/Position
      • Business telephone
      • Business fax

      CANPASS Private/Corporate Aircraft information while in Canada (attach a separate sheet if necessary)

      • 67. Airport of landing
      • 68. Aircraft location (FOB/Hangar)

      Please provide information for any aircraft on which you may be travelling

      • 69. Make
      • 70. Model
      • 71. Year
      • 72. Registration Number and Province of Registration

      Section G – Fee payment (non-refundable) - No fee required for applicants under 18 years of age.

      • CANPASS Corporate aircraft – CAN $40 per applicant for five years
      • CANPASS Private aircraft – CAN $40 per applicant for five years
      • I am enclosing a certified cheque or money order payable to the Receiver General for Canada.
      • If paying with a credit card you must include a phone number where you can be reached during business hours. The Canadian Processing Centre will contact you at the number provided to obtain your payment information. Please note that your application will not be processed until payment has been confirmed. We ask that you keep a copy of this application for reference.
        • I choose to pay using my credit card and I consent to being contacted by the Canadian Processing Centre.
        • Phone number
        • E-mail address
        • Cardholder's name (please print)
        • Cardholder's signature

        Section H – Non-custodial parent or legal guardian

        The person applying on behalf of a child under 18 years of age must either be the parent or the person who has custody or tutorship of the child under a court order if every parent and every other person who has custody or tutorship consent to the application. As such, documents such as a letter of consent from the other parent and the other person who has custody or tutorship is required. In addition, a court document stating the custodial agreement must be provided so that custody/tutorship can be verified as well as that there are no restrictions on removal from the custodial/tutorship jurisdiction.

        Section I – Certification

        Canada’s Privacy Statement

        The information you provide in your application, including supporting documentation, is collected by the Canada Border Services Agency (CBSA) under the authority of the Customs Act and is protected pursuant to both the Customs Act and the Privacy Act . In accordance with Canadian laws and regulations, this information will be shared with other government departments or agencies in Canada for the purpose of the operation of the CANPASS Corporate Aircraft or CANPASS Private Aircraft programs, and to conduct applicable checks and verifications to determine your eligibility and continued eligibility to any of these programs. If the required information is not provided, your application may not be processed and the authorization may not be granted.

        Information collected for the purpose of the operation of the CANPASS programs may also be disclosed within the CBSA and to other government departments or agencies (including the Royal Canadian Mounted Police and the Canadian Security Intelligence Service) for their use, in accordance with section 107 of the Customs Act .

        Individuals to whom the information relates have rights of access to, correction of and protection of, their personal information under the Privacy Act . The collection, use, disclosure and retention of your personal information is described in Personal Information Bank # CBSA PPU 002. Instructions for obtaining information are provided in the CBSA’s Information about Programs and Information Holdings (formerly Info Source), which is available at public libraries, government public reading rooms and on the Internet at: https://www.cbsa-asfc.gc.ca/agency-agence/reports-rapports/pia-efvp/atip-aiprp/infosource-eng.html.

        Individuals to whom the information relates also have the right to file a complaint to the Privacy Commissioner of Canada should they have a concern about how the CBSA handles their information. Instructions for filing a privacy complaint can be found at: https://www.priv.gc.ca/en/report-a-concern/file-a-formal-privacy-complaint/file-a-complaint-about-a-federal-institution/.

        Consent Statement

        I understand that any information gathered for the purposes of this application, including any supporting documentation or background information, as well as information obtained from the relevant files of law enforcement agencies, including intelligence gathered for law enforcement purposes, will be used for the purpose of the operation of the CANPASS Corporate Aircraft or CANPASS Private Aircraft programs, and to conduct applicable checks and verifications to determine eligibility and continued eligibility in the CANPASS programs as described in the Presentation of Persons (2003) Regulations. My contact information may also be used by the CBSA to send me notifications related to changes to the CANPASS program(s).

        If you do not consent to the above-noted collection, use and sharing of your personal information, your application cannot be processed and an authorization cannot be granted.

        Do you consent to the above-noted collection, use, and sharing of your personal information?

        Certification

        I certify that all information given on this application, and in support of this application, is provided voluntarily and is true, accurate and complete.

        I certify that I have read, understood, and agree to abide by all conditions applicable to the program to which I apply and to the use of the associated authorization, including all instructions and notices accompanying this application.

        Signature of applicant or signature of parent or legal guardian if applicant is under the age of 18:

        Name (print)
        Signature
        Date

        FOR OFFICE USE ONLY

        TDC Booklet no. (if applicable)

        How to complete the application

        Each person who wants to participate in a CANPASS program has to complete and sign an application form. Parents or legal guardians must complete the application on behalf of children less than 18 years of age. NOTE: Their processing fee is waived.

        The following provides additional details about certain sections of the application form.

        Preferred language - Indicate English or French. We will correspond with you in the language of your choice.

        CANPASS Programs - Indicate the program in which you want to participate. A separate application form is required for each applicant and program.

        Section A - Personal information

        Other names used - If you have ever changed your name (including by marriage), provide previous name(s).

        Citizenship and residency - Indicate whether you are a citizen of Canada, the United States, or another country. Check the box that corresponds with your country of residence.

        Proof of citizenship or permanent resident status - Provide a photocopy and check the type of the document(s) confirming your citizenship or permanent resident status. Provide the document number and expiry date, if applicable. For the Canadian permanent resident document number: provide the serial number located on the upper left of the back of the card, e.g., RA0123456789.

        Section B - Address history for the last 5 years - Provide details of your address history for the past five years. Use the space provided, starting with your current address. Attach a separate sheet, if necessary.

        Section C - Employment history for the last 5 years - Provide details of your employment history for the past five years. Use the space provided, starting with your current employer. Attach a separate sheet, if necessary. Lack of employment will not disqualify you from participation, if you are otherwise admissible to the United States and Canada, and meet all other program requirements.

        Section D - Purpose of your travel - If you are a United States citizen or resident alien you must indicate the purpose of your travel to Canada.

        Section E - Additional information - Indicate whether you have been convicted of a criminal offence. Also include any immigration and customs violations you may have experienced.

        Section F - Customs Programs

        • Corporate Aircraft Program - Complete boxes 59 to 71. Include the CANPASS Corporate Aircraft membership number if your corporation is affiliated with
          the program. Include the aircraft tail number and registration mark.
        • Private/Corporate Aircraft Program - Complete boxes 66 to 71. Include the aircraft tail number and registration mark.

        Section G - Fee payment - Include a money order or a certified cheque in Canadian funds, for applicant 18 years of age or older, made payable to the Receiver General for Canada. If you are paying by credit card, provide your VISA or MasterCard or AMEX number, including expiry date, along with your signature.Corporate Aircraft applicants do not need to include any form of payment (certified cheque, money order, or personal credit card number), as your corporation pays for the fee.
        

        Section H - Non-Custodial Parent or Legal Guardian - To meet Canadian requirements, non-custodial parents or legal guardians applying for a child under the age of 18, for whom they do not have legal custody, must attach a copy of the applicable legal documents showing custody rights, or a notarized copy of the parent or legal guardian's consent, in writing, for the enrolment of that child in the CANPASS program.

        Section I - Certification - Read the privacy statements and the certification statement on the application form carefully. Then, sign and date this section. For a child under the age of 18, the legal guardian or parent must sign this certification.

        Complete, sign the application form and send it with the non-refundable fee payment, along with your photocopied documents to the Canadian Processing Centre nearest you.

        CANPASS Corporate Aircraft and CANPASS Private Aircraft applications can be sent to any one of the three Canadian Processing Centres:

        Canadian Processing Centre Canadian Processing Centre
        28–176th Street
        Surrey BC V3S 9R9
        Telephone: 604-538-3689 / 1-866-496-3987

        Canadian Processing Centre
        400 Place d'Youville
        Montréal QC H2Y 2C2
        Telephone: 514-350-6137

        Canadian Processing Centre
        PO Box 126
        Niagara Falls ON L2E 6T1
        Telephone: 905-371-1477 / 1-800-842-7647