BSF814 - Pilot Project for Travellers In Remote Areas - Quebec (PPTRA-Q) Application Form

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Protected B when completed

Please type or print
We will not accept incomplete applications.

New application / Renewal

  1. Preferred language - English / French
  2. What is your main reason for applying? Pleasure / Work

Section A – Personal Information

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

Section B – Address history for the last five years

  1. Current address since: Year, Month
  2. Street address
  3. Apt.
  4. City
  5. Province/State
  6. Postal/Zip code
  7. Country
  8. Home telephone
  9. Business telephone
  10. Cellular telephone

Mailing address if different from residential address

  1. Street address
  2. Apt.
  3. City
  4. Province/State
  5. Postal/Zip code
  6. Country

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

  1. From: Year, Month
    To: Year, Month
  2. Street address
  3. Apt.
  4. City
  5. Province/State
  6. Postal/Zip code
  7. Country

Section C - Employment history for the last five years

  1. Current employer since: Year, Month
  2. Employer's name
  3. Street address
  4. City
  5. Province/State
  6. Postal/Zip code
  7. Country
  8. Telephone number Ext.
  9. If self-employed, please specify type of business:
  10. 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).

  1. From: Year, Month
    To: Year, Month
  2. Employer's name
  3. Street address
  4. City
  5. Province/State
  6. Postal/Zip code
  7. Country

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

  1. 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 YYYY MM DD

If the purpose of your travel to Canada will be for business, work, or study, you may have to obtain written authorization from Immigration, Refugees and Citizenship Canada (IRCC) before joining the program. Contact a IRCC office in Canada or any Canadian consular office abroad.

Section E - Additional Information

  1. 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 in Canada for which a pardon or rehabilitation has not be granted? Yes / No
    • If you are a U.S. citizen or U.S. permanent resident, do you have a Federal Bureau of Investigation (FBI) criminal history record? If yes, please submit it with your application. Yes / No

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

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

Section G - 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 other person who has custody or tutorship is required. In addition, a court document stating the custodial or tutorship 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 H - Certification

Privacy Statement

The information you provide in your application, including supporting documentation, is collected by the 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 Pilot Project for Travellers in Remote Areas - Quebec (PPTRA-Q) program, and to conduct applicable checks and verifications to determine your eligibility and continued eligibility in the PPTRA-Q program. 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

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 PPTRA-Q program, and to conduct applicable checks and verifications to determine eligibility and continued eligibility in the PPTRA-Q program as described on the website at https://www.cbsa-asfc.gc.ca/travel-voyage/pptraq-ppvreq-eng.html. My contact information may also be used by the CBSA to send me notifications related to changes to the PPTRA-Q program.

In addition, I understand that my personal information gathered for the purpose of this application, including my supporting documentation, background information, and any other information obtained and collected for the purpose of the operation of the PPTRA-Q program and to conduct applicable checks and verifications to determine my eligibility and continued eligibility in the program, 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:

For office use only

Payment


Please submit your completed application along with your CAN $50 application fee to the following address:

Canadian Processing Centre
400 Place d'Youville
Montreal, QC
H2Y 2C2

Telephone: 1-866-399-5887

How to complete the application

Each person who wants to participate in the PPTRA-Q 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.

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 - 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.

Section G - 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 PPTRA-Q program.

Section H - Certification - Read the privacy statement, consent statement 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.

Mail your signed application along with the non-refundable fee payment and your photocopied proof of citizenship/residency/ immigration status documents to the following Canadian Processing Centre:

Canadian Processing Centre
400 Place d'Youville
Montreal, QC
H2Y 2C2

Checklist before submitting application

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