Fillable Printable Request for Police Certificates/Clearances and Authorization for Release of Information
Fillable Printable Request for Police Certificates/Clearances and Authorization for Release of Information
Request for Police Certificates/Clearances and Authorization for Release of Information
Citizenship and
Immigration Canada
Citoyenneté et
Immigration Canada
Request for Police Certificates/Clearances and
Authorization for Release of Information
To Police or Relevant Authorities:
Canada Immigration requires the person named below to obtain an original police certificate
for every country where he or she has lived for six months or longer since the age of 18. The
applicant has provided details in the box below that may assist you in processing the request
and has also signed the form authorizing you to release the information to us.
Surname
Given name(s)
Other surname(s) used (example maiden name, previous married names)
Name in original script (example Farsi, Arabic, Chinese, etc.)
Date of birth
Day Month Year
Place of birth
Sex
Male
Female
Citizenship
Current address in Canada (number, street, city, province and postal code)
DATES
ADDRESS(ES) WHILE RESIDENT IN ______________________
(Name of country)
FROM
Month Year
TO
Month Year
I authorize the police or relevant authorities in the country/state named above to disclose to
Immigration Canada details about any previous criminal convictions that may exist.
Day Month Year
_________________________________
Signature of applicant Date
Please send the police certificate directly to the applicant. If you are unable to provide a
certificate/clearance, please send the applicant a written explanation. Thank you.
Immigration officer
