Child Under 16 Travel Document Application - Canada

Child Travel Document Application
for stateless and protected persons in Canada (under 16 years of age)
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 Canadian travel document, the revocation of a valid Canadian travel document, or the refusal of travel document 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 travel document services.
Type or print in CAPITAL LETTERS using black or dark blue ink.
Child's Personal Information (see Instructions, section G)
1
Surname (last name)
Given name(s)
Surname (last name) at birth
Former surname (last name)
Date of birth
Year
Month Day
Place of birth
City Country Province/Territory(if applicable)
Sex
Female
Male
Eye colour Current hair colour Height
(cm/in)
Weight
(kg/lbs)
Current home address
Number Street Apartment City
Province/Territory Postal code
Mailing address (if different from above)
Number Street Apartment City
Province/Territory Postal code
Children 11 years of age or over must sign in this signature box.
Note: At no time should a person other than the child sign in this
signature box, without exception.
Date
Year
Month Day
Signed at
City
Province/Territory
Sign within border
Signature of child (see Instructions, section G)
Information on Applicant (see Instructions, section I)
2
Is the child currently the subject of an adoption process or partially or fully in
the care of a provincial/territorial family services organization in Canada?
No Yes
Are there any separation agreements, court orders or legal proceedings
pertaining to custody of, mobility of, or access to the child?
No Yes
If yes, include all documents
Relationship between the applicant (parent or legal guardian) and the other parent or legal guardian
Date of marriage (if applicable)
Year
Month Day
Applicant (parent or legal guardian)
Surname (last name) at your birth
Given name(s)
Date of birth
Year
Month Day
Country of birth
Address
(Number, Street, Apartment, City, Province/Territory, Postal code)
Telephone (daytime) Telephone (other)
Cell number (optional)
Declaration—I declare that I am the parent or legal guardian of this child and that the
statements made in this application are true. I declare that I have read and understood the
Warning at the top of this page and the Privacy Notice Statement (see section P). I consent
to the collection, use and disclosure of my personal information and that of the child 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.
Signature of applicant (also sign section 4) Date Signed at
Other parent or legal guardian
Surname (last name) at your birth
Given name(s)
Date of birth
Year
Month Day
Country of birth
Address
(Number, Street, Apartment, City, Province/Territory, Postal code)
Telephone (daytime) Telephone (other)
Cell number (optional)
Declaration—I declare that I am the parent or legal guardian of this child and that the
statements made in this application are true. I declare that I have read and understood the
Warning at the top of this page and the Privacy Notice Statement (see section P). I consent
to the collection, use and disclosure of my personal information and that of the child 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.
Signature of other parent or legal guardian
Date Signed at
Aussi accessible en français
- Page 1 of 10
PPTC 192 (2015-05) R1
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Child Under 16 Travel Document Application - Canada PDF

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