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hold open to Officio Citizenship and Immigration Canada Citoyennete et Immigration Canada PROTECTED WHEN consummate B PAGE 1 OF 4 SCHEDULE A range / DECLARATION The principal applicant, his or her spouse or common-law subprogramner, if applicable, and every last(predicate) dependent children hoary 18 years or older listed in the application for permanent residence must complete their own retroflex of this take. If there is non enough space to provide all the required information, attach to this form a separate sheet of paper with still enlarge.Print your visit at the top of each additional sheet and signify the forms title and the consequence of the question you ar answering. Before you start complemental this form, bewilder enough photocopies for your needs. You can also target all or part of this form from our Web site at www. cic. gc. ca. BEFORE YOU START, drive THE INSTRUCTION GUIDE TYPE or PRINT in gloomy ink Indicate whether you are The principal applicant 1. Your full pay heed Family score The spouse, common-law partner or dependent child aged 18 years or older of the principal applicant 6.Have you, or, if you are the principal applicant, every of your family members listed in your application for permanent residence in Canada, ever YES NO a) been convicted of a umbrage or offence in Canada for which a pardon has non been granted under the Criminal Records routine of Canada? b) been convicted of, or are you currently charged with, on trial for, or party to a crime or offence, or subject of some(prenominal) criminal proceedings in any different area? c) do previous claims for refugee protection in Canada or at a Canadian endorse office abroad, in any some new(prenominal) country or countries, or with the United Nations High Commissioner for Refugees (UNHCR)? ) been ref utilize refugee status, an immigrant or permanent resident visa (including a Certificat de selection du Quebec (CSQ) or application to the Provincial Nomin ee Program) or visitor or temporary resident visa, to Canada or any other country? e) been refused admission to, or ordered to present, Canada or any other country? f) been involved in an act of genocide, a war crime or in the commission of a crime against humanity? conflict of birth Town/ urban center of birth Country of birth go out of death, if deceased 5. course Month Day Tito springn name(s) Roderick 2. Your full name written in your native language or script (e. . , Arabic, Cyrillic, Chinese, Korean, Nipponese characters or Chinese commercial/telegraphic code) Roderick M. Tito 3. 4. Your date of birth form Month Day 1972 01 17 Personal lucubrate of your father Family name Tito Given name(s) Felix 1 9 1 2 1 2 0 8 Danao city, Cebu Philippines Year Month Day g) used, planned or advocated the use of build up struggle or violence to reach political, spectral or fond objectives? h) been associated with a group that used, uses, advocated or advocates the use of armed stru ggle or violence to reach political, religious or social objectives? ) been member of an arrangement that is or was engaged in an activity that is part of a pattern of criminal activity? j) been detained, incarcerated or put in jail? 1 9 9 8 Personal flesh out of your mother Family name at birth k) had any serious complaint or physical or mental disorder? Tito If your answer to any of these questions is YES, provide details beneath. Given name(s) Fedilinda Date of birth Town/ city of birth Country of birth Date of death, if deceased 1 9 4 7 0 4 2 7 Year Month Day Danao urban center, Cebu Philippines Year Month DayThis form is make visible(prenominal) by Citizenship and Immigration Canada and is not to be sold to applicants. IMM 5669 (07-2011) E (DISPONIBLE EN FRANCAIS IMM 5669 F) Save to Officio PAGE 2 OF 4 7. Education Give the number of years of rail you successfully completed for each of the pursuance levels of education. bare(a)/ primary school Secondary/ gamy school University/ college Trade school or other brandmark secondary school 6 4 1. 5 Give full details of all the secondary and erect secondary education (including university, college and apprenticeship training) you tolerate had.From To Type of certificate or touch of institution City and country diploma issued Y M M Y 2 0 1 1 1 1 2 0 1 2 0 3 2 0 1 2 0 3 2 0 1 2 0 3 1 9 9 7 1 2 1 9 9 7 1 2 1 9 9 7 0 6 1 9 9 7 0 7 BMC didactics Center for conjoin and deceitfulness Inc. BMC Training Center for Welding and Fabrication Inc. MIAP Training and Service Center / TESDA Region VII technological Education and Skills schooling office staff ( TESDA Region VII ) Mandaue Technical name Mabolo Cebu City, Philippines Mabolo Cebu City, Philippines Cebu City, Philippines Cebu City, Philippines 1 9 9 4 0 6 1 9 9 5 0 4 8. Personal historyMandaue City, Cebu Philippines protect Metal Arc Welding NC II ( 360 hrs. ) Industrial Pipefitting NC II ( 160 hrs. ) Industrial Pipefitting Course ( 80 hrs. ) Refrigeration and expression Conditioning 10 months Basic Seaman Course Provide the details of your personal history since the age of 18, or the past 10 years, whichever comes first. pass over with the most recent information. Under Activity, write your occupation or line title if you were working. If you were not working, provide information on what you were doing (for typeface unemployed, studying, travelling, retired, in detention, etc. ).Note Please ensure that you do not countenance any gaps in time. Failure to account for all time periods entrust result in a delay in the processing of your application. From Y M Y To M Activity Welding Instructor and tonal patterncon Techinician City or town and country Cebu City, Philippines get a line of company, employer, school, facility, as applicable hopeful Metal Craft Training Center for Welding and Fabrication Inc. 2 0 1 2 0 6 2 0 1 2 12 2 0 1 0 12 2 0 1 2 0 3 electromechanical Supervisor Servicing Department Supervisor Machin ist / slit steward Machinist / Fitter Mandaue City, Philippines Mandaue City, PhilippinesMEPZ- I ,Mactan Island, Cebu, Philippines MEPZ- I ,Mactan Island, Cebu, Philippines ZERCOOL POWER Airconditioning and electrical service B and A TRADING and Airconditioning work ABTECH Machineries and technology Services Corp. ATA Engineering and Technology Consortium Inc. 1 9 9 7 0 6 2 0 1 0 12 1 9 9 4 0 4 1 9 9 6 12 1 9 9 2 1 1 1 9 9 4 0 3 9. Membership or association with organizations What organizations deal you supported, been a member of or been associated with? Include any political, social, youth or scholar organization, trade unions and professional associations. Do not use abbreviations.Indicate the city and country where you were a member. compose no(prenominal) in the nook if you have not been a member of any association/organization. From Y M Y To M Name of organization Insovilla Plains Homeowners Association BMC Assistant Instructor no(prenominal) Type of organization SO CIAL STUDENT Activities and/or positions held within organization PRESIDENT PRESIDENT City and country Lapu-lapu City, Cebu Philippines Cebu City, Philippines 2 0 0 7 0 3 2 0 1 2 2 0 1 2 0 5 2 0 1 2 0 6 none no(prenominal) 10. Government positions List any government positions (such as civil servant, judge, guard officer) you have held. Do not use abbreviations.Write no(prenominal) in the box if you have not held any government position. From Y M Y To M Country and level of jurisdiction (e. g. national, regional, municipal) NONE Department/ counterbalance Activities and/or positions held NONE NONE NONE NONE IMM 5669 (07-2011) E Save to Officio PAGE 3 OF 4 11. Military service Provide below details of military service for each of the countries in whose armed forces you served. Write NONE in the box if you have not undertaken military service. Name of country NONE From Y M Y To M separate of service, unit poesy and names of your commanding officers Rank(s) Dates and places of any active combatNONE NONE NONE NONE NONE NONE Name of country NONE From Y M Y To M Branch of service, unit numbers and names of your commanding officers Rank(s) Dates and places of any active combat NONE NONE NONE NONE NONE NONE 12. Addresses List all addresses where you have lived since your 18th birthday. Do not use P. O. box addresses. From Y M Y To M Juan Luna route 749 M. L Quezon St. Cabancalan Insovilla Plains, Marigondon Street and number City or town Province, State or soil Country 1 9 9 0 0 1 1 9 9 3 0 1 1 9 9 3 0 1 2 0 0 0 0 3 Danao City Mandaue CIty Lapu-lapu City Cebu Cebu Cebu Philippines Philippines Philippines 0 0 0 0 3 2 0 1 2 12 IMM 5669 (07-2011) E Save to Officio PAGE 4 OF 4 Authority to disclose personal information By submitting this form, you consent to the release to Canadian government authorities of all records and information any government authority, including police, juridical and state authorities in all countries in which you have lived may possess o n your behalf concerning any investigations, arrests, charges, trials, convictions and sentences. This information entrust be used to assist in evaluating your suitability for admission to Canada or remaining in Canada pursuant to Canadian legislation.Declaration of applicant I declare that the information I have given is truthful, complete and correct. Year Month Day touching Date DO NOT COMPLETE THE FOLLOWING SECTION NOW. YOU whitethorn BE ASKED TO SIGN IN THE PRESENCE OF A REPRESENTATIVE OF THE Canadian GOVERNMENT OR AN OFFICIAL APPOINTED BY THE CANADIAN GOVERNMENT. horrible contract I, , do solemnly declare that the information I have given in the foregoing application is truthful, complete and correct, and I make this solemn declaration conscientiously believing it to be true and knowledgeable that it is of the same force and performance as if made under oath.Interpreter declaration I, , do solemnly declare that I have faithfully and accurately interpreted in the language the content of this application and any link forms to the person concerned. I have been informed by the person concerned, and I do verily believe, that he or she completely understands the nature and effect of these forms, and I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as is made under oath. Signature of applicant Signature of interpreterDeclared before me at Canadian Government official this day of of the year Name Please print or type Signature The information you provide on this form is collected under the authority of the Immigration and Refugee Protection Act and give be used for the purpose of assessing your application for permanent residence. It will be stored in Personal Information Banks (PPU 039 entitled Overseas Immigration slip-up File and PPU 042 entitled Immigrant Case File). It may be shared with other organizations in accordance with the consistent use of information under the concea ling Act.Under the provisions of the Privacy Act and the Access to Information Act, individuals have the set to protection of and access to their personal information. Details on these matters are open at the Infosource website (http//infosource. gc. ca) and are also available at public libraries crossways Canada. IMM 5669 (07-2011) E Family Name Tito Save to Officio Given Name Roderick . 7. Education Give the number of years of school you successfully completed for each of the following levels of education. Elementary/ Secondary/ University/ 6 4 primary school high school collegeADDENDUM 1. 5 Trade school or other post secondary school Give full details of all the secondary and post secondary education (including university, college and apprenticeship training) you have had. From Y M Y To M Name of institution BMC Training Center for Welding and Fabrication Inc. City and country Mabolo Cebu City, Philippines Mabolo Cebu City, Philippines Cebu City, Philippines Cebu City, Philipp ines Type of certificate or diploma issued protect Metal Arc Welding NC II ( 360 hrs. ) Industrial Pipefitting NC II ( 160 hrs. ) Industrial Pipefitting Course ( 80 hrs. Refrigeration and Air Conditioning 10 months Basic Seaman Course 2 0 1 1 1 1 2 0 1 2 0 3 2 0 1 2 0 3 2 0 1 2 0 3 1 9 9 7 12 1 9 9 7 12 1 9 9 7 0 6 1 9 9 7 0 7 BMC Training Center for Welding and Fabrication Inc. MIAP Training and Service Center / TESDA Region VII Technical Education and Skills Development Authority ( TESDA Region VII ) Mandaue Technical Institute 1 9 9 4 0 6 1 9 9 5 0 4 . 8. Personal history Mandaue City, Cebu Philippines Provide the details of your personal history since the age of 18, or the past 10 years, whichever comes first. outset with the most recent information.Under Activity, write your occupation or job title if you were working. If you were not working, provide information on what you were doing (for example unemployed, studying, travelling, in detention, etc. ). Note Please ensure that you do not leave any gaps in time. Failure to account for all time periods will result in a delay in the processing of your application. From Y M Y To M Activity Welding Instructor and Aircon Techinician City or town and country Cebu City, Philippines Name of company, employer, school, facility, as applicable magnificent Metal Craft Training Center for Welding and Fabrication Inc. 0 1 2 0 6 2 0 1 2 12 2 0 1 0 12 2 0 1 2 0 3 Electromechanical Supervisor Servicing Department Supervisor Machinist / Tool keeper Machinist / Fitter Mandaue City, Philippines Mandaue City, Philippines MEPZ- I ,Mactan Island, Cebu, Philippines MEPZ- I ,Mactan Island, Cebu, Philippines Mandaue City, Philippines Danao City, Philippines ZERCOOL POWER Airconditioning and Electrical Services B and A TRADING and Airconditioning Services ABTECH Machineries and Engineering Services Corp. ATA Engineering and Technology Consortium Inc. 1 9 9 7 0 6 2 0 1 0 12 1 9 9 4 0 4 1 9 9 6 12 1 9 9 2 1 1 1 9 9 4 0 3 9 9 2 1 1 1 9 9 3 0 5 1 9 9 0 0 4 1 9 9 2 10 Production Worker Coal Miner Sunpride Foods, Inc. Almendras minelaying Corporation 12. Addresses List all addresses where you have lived since your 18th birthday. Do not use P. O. box addresses. From Y M Y To M Street and number City or town Province, State or District Country 1 9 9 0 0 1 1 9 9 3 0 1 1 9 9 3 0 1 2 0 0 0 0 3 Juan Luna Street Danao City Cebu Philippines 749 M. L Quezon St. Cabancalan Insovilla Plains, Marigondon Mandaue CIty Lapu-lapu City Cebu Cebu Philippines Philippines 2 0 0 0 0 3 2 0 1 2 12 IMM 5669 (07-2011) E .