Adult Simplified Renewal Passport Application

Adult Simplified Renewal Passport Application
for eligible Canadians applying in Canada or from the USA
Protected B when completed
Warning—Any false or misleading statement with respect to this application and any supporting document, including
the concealment of any material fact, may result in the refusal to issue a passport, the revocation of a currently valid
passport, or the refusal of passport services, and may be grounds for criminal prosecution. Your application will not be
processed if you fail to complete all of the required sections of this form and/or refuse to consent to the exchange or
disclosure of any personal information required for the delivery of passport services.
Type or print in CAPITAL LETTERS using black or dark blue ink.
Personal Information (see Instructions, section H)
1
Surname (last name)
Given name(s)
Surname (last name) at birth
Former surname (last name) Mother's maiden name
Date of birth
Year Month Day
Place of birth
City Country Prov./Terr./State (if applicable)
Sex
Female
Male
Marital status Eye colour Current hair colour Height
(cm/in)
Weight
(kg/lbs)
Current home address
Number Street Apartment City
Province/Territory/State Postal/ZIP code
Mailing address (if different from above)
Number Street Apartment City
Province/Territory/State Postal/ZIP code
Telephone (daytime)
Telephone (other) Cell number or email address
(optional)
Declaration—I solemnly declare that I am a Canadian citizen, that the
photos enclosed are unaltered and a true likeness of me, that all of the
statements made and the information provided in this application, as well
as any supporting documents, are true. I declare that I have read and
understood the Warning at the top of this page and the Privacy Notice
Statement (see instructions section K). I consent to the collection, use
and disclosure of my personal information by Passport Program,
Citizenship and Immigration Canada, other federal government
institutions, Government of Canada offices abroad and third party entities
as outlined in the Privacy Notice Statement in the Instructions.
Sign within border
Signature (see Instructions, section H)
Date
Year Month Day
Signed at
City
Province/Territory/State
Date of travel
Unknown
Month Day
Previous Canadian Passport (see Instructions, section I)
2
Enclose any Canadian passport issued to you
within the last six (6) years.
Number
Date of issue
Year
Month Day
Date of expiry
Year Month Day
If you cannot submit the previous passport, or if the previous passport is damaged, you cannot use this form.
Would you like the previous passport returned to you? If not, it will be securely destroyed by Passport Program to protect your
personal information.
Yes, please return the previous passport to me.
Canadian Citizenship
3
To be completed if you were born outside of Canada between February 15, 1977 and April 16, 1981 inclusive.
a) Are you a naturalized Canadian, i.e. did you receive
Canadian citizenship following immigration to Canada?
Yes – Go to page 2 No – Continue to question b)
b) Was one of your parents born in Canada?
Yes – Go to page 2 No – Continue to question c)
c) When was your current certificate of Canadian citizenship issued?
After January 1, 2007
Before January 1, 2007
Submit the certificate with your application (original only).
Complete and submit form PPTC 001, Proof of Canadian Citizenship—Additional Information,
available online at passportcanada.gc.ca.
Aussi accessible en français
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Adult Simplified Renewal Passport Application PDF

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