Citizenship and Immigration Canada PROTECTED WHEN COMPLETED - B Citoyenneté et Immigration Canada CANEDA, T 1995/1/1 PAGE 1 OF 2 SCHEDULE 1 APPLICATION FOR TEMPORARY RESIDENT VISA The principal applicant, his or her spouse or common-law partner, if applicable, and all dependent children aged 18 years or older listed in the application for temporary residence must complete their own copy of this form. The Principal Applicant(申請者本 人）にチェック The principal applicant *Indicate whether you are 1 2 Taro 無 ロホ 料 リ エ カ ー ナ ジ ダ ェ ン ト IA J Caneda P １Family Name （苗字） Given Name （名前） ２．Date of Bith (誕生日） The spouse, common-law partner or dependent child aged 18 years or ３．UCI（＝Client No）学生ビ older of the principal applicant ザ（就学許可証）などをお持ちの 方。許可証にClient Noを記入。 YYYY 1 9 9 MM 5 0 1 DD 3 UCI 0 1 Canada places a high value on bringing those who commit acts of genocide, war crimes or crimes against humanity to justice. Canada was the first country to incorporate the obligations of the Rome Statute into its national laws. 4 ４． 今までに軍隊、自衛隊、セキュリティ警 備、警察などでの勤務の経験があります か？militia, or civil defence unit or serve in a security organization or police force (including non obligatory national service, reserve or volunteer units)? Did you serve in any military, Military Service *No From YYYY *Yes Give the following details: To MM YYYY Location/Place where stationed MM Province Country Yes の場合は、詳細を記 入してください。 Add more rows 5 + Have you ever witnessed or participated in the ill treatment of prisoners or civilians, looting or desecration of religious buildings? *No From Details: Details: あなたは今までに囚人や民間人への虐待、宗教建物の冒涜や横領に参 加もしくはたち合ったことがありますか？ Give the following details: To MM ゼ YYYY *Yes YYYY MM Location Province Country Yes の場合は、詳細を記 入してください。 - - Details: Add more rows IMM 5257 (02-2015) Schedule 1 This form is made available by Citizenship and Immigration Canada and is not to be sold to applicants. (AUSSI DISPONIBLE EN FRANÇAIS - IMM 5257 F - Annexe 1) + Citizenship and Immigration Canada 6 PROTECTED WHEN COMPLETED - B Citoyenneté et Immigration Canada 6．あなたは今までに政治団体、もしくは政治、宗教などを目的とする暴力的と見られる団体組織、犯罪行為に協力・関係したことがありますか？ CANEDA, T 1995/1/1 PAGE 2 OF 2 略語を使わないでください。 Membership or Association with Organizations Are you, or have you ever been a member or associated with any political party, or other group or organization which has engaged in or advocated violence as a means to achieving a political or religious objective, or which has been associated with criminal activity at any time? Do not use abbreviations. *No *Yes From YYYY MM Give the following details: YYYY To MM Name of organization Activities and/or positions held within organization Province Country Yes の場合は、詳細を記 入してください。 - Government Positions 無 ロホ 料 リ エ カ ー ナ ジ ダ ェ ン ト IA J 7 P Add more rows + Have you ever held any government positions (such as civil servant, judge, police officer, mayor, member of parliament, hospital administrator)? Do not use abbreviations. *No From YYYY *Yes Give the following details: To MM MM YYYY Country 7．あなたは今までに政府関係のポジションにいたことがありますか？ （市民サービスや裁判、警官、市長、議員、医療事務(管理職）のような） 略語を使わないでください。 Level of jurisdiction (e.g. national, regional, municipal) Department/Branch Activities and/or positions held Yes の場合は、詳細を記 入してください。 Add more rows 8 + Previous Travel Since the age of 18 or during the past five years, whichever is more recent, have you travelled to any country other than the country of your citizenship or your current country of residence? *No From YYYY *Yes Give the following details: 8．18歳以降、もしくは最近過去5年間のどちらかの最近で国籍以外の国、もしくは現在 滞在している国以外で旅行に行かれたことがありますか？ To MM YYYY Country MM Location Purpose of Travel ゼ Yes の場合は、詳細を記 入してください。 Add more rows Valid IMM 5257 (02-2015) Schedule 1 確認して「Vaild」ボタンをク リック This form is made available by Citizenship and Immigration Canada and is not to be sold to applicants. (AUSSI DISPONIBLE EN FRANÇAIS - IMM 5257 F - Annexe 1) +
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