E672 – CANPASS Application Form

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Protected B when completed

Please print - We will not accept incomplete applications.

  • 1. Preferred language (English/French)
  • 2. Original/Duplicate/Amended (Membership no.)
  • 3. Indicate the program you are applying for. A separate application form is required for each applicant and program.
    • CANPASS Air
      • Preferred Interview Location
    • CANPASS Private Aircraft
    • CANPASS Corporate Aircraft
    • CANPASS Private Boat

Section A – Personal Information

  • 4. Last name
  • 5. First name
  • 6. Middle name
  • 7. Other last names used (e.g., maiden name, former name)
  • 8. Other first names (nickname)
  • 9. Gender (Male/Female)
  • 10. Date of birth (YYYY-MM-DD)
  • 11. Place of birth – City
  • 12. Province/State
  • 13. Country
  • 14. Citizenship
    • Canadian citizen
    • U.S. citizen
    • Other (please specify)
  • 15. Residence
    • Canada
    • United States
    • Other (please specify)
  • 16. Proof of citizenship/residency/immigration status (check all that apply)
    • Birth certificate no.
    • Passport no.
      • Country of issuance
      • Expiry date (YYYY-MM-DD)
    • Citizenship card no.
    • Permanent resident document no.
    • U.S. alien registration no.
      • Expiry date (YYYY-MM-DD)
    • Other
      • Type of document
      • No.

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

Mailing address if different from residential address

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

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

  • 33. From: (YYYY-MM) to: (YYYY-MM)
  • 34. Street address
  • 35. Apt.
  • 36. City
  • 37. Province/State
  • 38. Postal/Zip code
  • 39. Country

Section C – Employment history for the last five years

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

  • 50. From: (YYYY-MM) to: (YYYY-MM)
  • 51. Employer's name
  • 52. Street address
  • 53. City
  • 54. Province/State
  • 55. Postal/Zip code
  • 56. Country

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

  • 57. What is the purpose of your travel to Canada? (check all applicable boxes)
    • Pleasure
    • Business/Work
    • Study
    • Other (specify)
  • Attached is a copy of my employment/student authorization issued by: (Canada/U.S.)
    • Expiry date
  • If the purpose of your travel to Canada will be for business, work, or study, you may have to obtain written authorization from Citizenship and Immigration Canada (CIC) before joining the program. Contact a CIC office in Canada or any Canadian consular office abroad.

Section E – Additional information

  • 58. 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 answered "Yes" to any of these questions, please provide details (use separate sheet if necessary).

Section F – Customs programs

(complete if applicable)

CANPASS Corporate Aircraft

Company information

  • 59. Company name
  • 60. Address
  • 61. City
  • 62. Province/State
  • 63. Postal/Zip code
  • 64. Mailing address (if different from above)
  • 65. 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)

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

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

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

CANPASS Private Boats – Vessel information

(attach a separate sheet if necessary)

  • 72. Vessel registration number/name/Province of registration
  • 73. Make
  • 74. Model
  • 75. Year
  • 76. Sail / Inboard / Outboard / Inboard/Outboard
  • 77. Hull/Manufacturer's serial no.
  • 78. Length
  • 79. Colour
  • 80. Marina name
    • 81. Address
    • 82. City
    • 83. Province/State
    • 84. Postal/Zip code

Section G – Fee payment (non-refundable)

No fee required for applicants under 18 years of age.

  • CANPASS Air – CAN $50 per applicant annually
  • CANPASS Private aircraft – CAN $40 per applicant for five years
  • CANPASS Corporate aircraft – CAN $40 per applicant for five years
  • CANPASS Private boats – CAN $40 per applicant for five years
  • I am enclosing a certified cheque or money order payable to the Receiver General for Canada.
  • Credit Card
    • Visa / MasterCard / AMEX
    • Card no.
    • Expiry date (MM/YY)
    • Cardholder's name (please print)
    • Cardholder's signature

Section H – Non-custodial parent or legal guardian

Non-custodial parents or legal guardians must attach a copy of supporting documents, such as a court order or letter of authorization, if this application is for a child under the age of 18 who will be traveling with a non-custodial adult.

Section I – Certification

Privacy Statement

Canada Border Services Agency (CBSA) 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 Air, CANPASS Corporate Air, CANPASS Private Air or CANPASS Private Boats 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.

Individuals to whom the information relates have rights of access to, correction of and protection of, their personal information under the Privacy Act. The information collected is described in Personal Information Bank # CBSA PPU 002. Instructions for obtaining information are provided in Info Source, which is available at public libraries, government public reading rooms and on the Internet at: http://infosource.gc.ca.

Consent Statement

I understand that any information gathered for the purposes of this application, including any supporting documentation or background information (and in the context of CANPASS Air, biometric data), 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 Air, CANPASS Corporate Air, CANPASS Private Air or CANPASS Private Boats 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).

In addition, I understand that my personal information gathered for the purposes of this application, including my supporting documentation, background information, (and in the context of CANPASS Air, biometric data), and any other information obtained and collected for the purpose of the operation of the CANPASS programs and to conduct applicable checks and verifications to determine my eligibility and continued eligibility in the program(s), may be accessed and used by the CBSA, as well as by other government departments or agencies in Canada (including the Royal Canadian Mounted Police and the Canadian Security Intelligence Service), in accordance with the Privacy Act.

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?

Yes/No

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

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.

Preferred Interview location - for CANPASS Air only. Indicate the airport in which you want to have your interview. Please visit the following CBSA site for a list of available Enrolment Centers: http://www.cbsa-asfc.gc.ca/prog/canpass/canpassair-eng.html#s2x2.

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 - excluding CANPASS Air

  • 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.
  • Private Boat Program - Complete boxes 72 to 84. Include your boat's name and registration number.

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 Air applications must be sent to either:

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

OR

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

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

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
6080 Mcleod Road
P.O. Box 126
Niagra Falls, ON L2G 7T4

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