Rehabilitation for persons who are inadmissible to Canada because of past criminal activity (IMM 5312)

Completing your application

You must provide truthful and accurate information. The information provided may be verified. Providing false or misleading information will likely result in a refusal of your application and may permanently bar your admission to Canada.

As most of the form is self-explanatory, supplementary instructions have only been provided where necessary. Attach a separate sheet of paper if you need more space and indicate the section, number and title of the question you are answering.

Section A

1. If you have determined that you are eligible to apply for rehabilitation, put a check mark in the box.

2. If you are not eligible to apply, but would like to discuss options for entering Canada (see Coming to, or Remaining in Canada Without Approval of Rehabilitation), put a check mark in the box.

Section B

1. Print your name as it appears in your passport or on your travel document or other valid identity document. Do not use initials; print names in full. For people living in the People’s Republic of China, also print names in pin yin.

2. State your date of birth in the following format: Day/Month/Year.

5. If you are a citizen of more than one country, print the names of all the countries.

7. Print all the names that you have ever used, including different spellings of your name. Explain what these names are, example, Maggie – nickname, Smith – previous married name, Leroux – birth/maiden name, Smith, John – change of name on 11 August, 2000, Chicago, IL, USA.

14. Print a list of offences that you have committed. Include the name of the offence, the name and section of law, the date of your conviction, the city, province/state/county and country where it occurred, and the sentence that was imposed. If you were not convicted of the offence, print “no conviction” and enter the date of the offence instead of the date of conviction, and include the date the courts dealt with your case and the disposition (i.e. not guilty, dismissed).

15. Describe the events that led to your committing the offence(s). Include a description of your actions, explain if weapons, drugs or alcohol were involved, why you did it, and how your actions affected others (specify any physical or emotional injuries). Be clear, concise and complete. You must complete this question in detail.

16. If you are applying to come to Canada as a temporary resident, indicate the dates of your proposed travel and describe the purpose of your trip.

If you are in Canada, state the date of your arrival in Canada and describe the purpose of your trip.

If you are applying to live in Canada permanently, indicate what type of application you will make. i.e. spouse or parent of a Canadian citizen or permanent resident, business person, refugee, skilled worker, etc. Print the names of all your immediate family members in Canada.

17. Tell us why you consider yourself rehabilitated. Provide as much information as possible, e.g. attended drug rehabilitation program, employment history, community service, etc. You must complete this question in detail.

20. Read this section carefully and sign the form.

Section C

Do not complete this section; it is for office use only. However, include it with your application.

Use of a Representative (IMM 5476)

Complete this form if you are appointing a representative.

If you have dependent children aged 18 years or older, they are required to complete their own copy of this form if a representative is also conducting business on their behalf.

A representative is someone who has your permission to conduct business on your behalf with Citizenship and Immigration Canada. When you appoint a representative, you also authorize CIC to share information from your case file to this person.

You are not obliged to hire a representative. We treat everyone equally, whether they use the services of a representative or not. If you choose to hire a representative, your application will not be given special attention nor can you expect faster processing or a more favourable outcome.

The representative you appoint is authorized to represent you only on matters related to the application you submit with this form. You can appoint only one representative for each application you submit.

There are two types of representatives:

Unpaid representatives

• friends and family members who do not charge a fee for their advice and services
• organizations that do not charge a fee for providing immigration advice or assistance (such as a non-governmental or religious organization)
• consultants, lawyers and Québec notaries who do not, and will not, charge a fee to represent you

Paid representatives

If you want us to conduct business with a representative who is, or will be charging a fee to represent you, he or she must be authorized. Authorized representatives are:

• immigration consultants who are members in good standing of the Canadian Society of Immigration Consultants (CSIC)
• lawyers who are members in good standing of a Canadian provincial or territorial law society and students-at-law under their supervision
• notaries who are members in good standing of the Chambre des notaires du Québec and students-at-law under their supervision

If you appoint a paid representative who is not a member of one of these designated bodies, your application will be returned. For more information on using a representative, visit our website.

Section B.

5. Your representative’s full name

If your representative is a member of CSIC, a law society or the Chambre des notaires du Québec, print his or her name as it appears on the organization’s membership list.

8. Your representative’s declaration

Your representative must sign to accept responsibility for conducting business on your behalf.

Section D.

10. Your declaration

By signing, you authorize us to complete your request for yourself and your dependent children under 18 years of age. If your spouse or common-law partner is included in this request, he or she must sign in the box provided.

Release of information to other individuals

To authorize CIC to release information from your case file to someone other than a representative, you will need to complete form Authority to Release Personal Information to a Designated Individual (IMM 5475) which is available on our website and from Canadian embassies, high commissions and consulates abroad.

The person you designate will be able to obtain information on your case file, such as the status of your application. However, he or she will not be able to conduct business on your behalf with CIC.

You must notify us if your representative’s contact information changes or if you cancel the appointment of a representative.

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