🍁

    Asylum Application Questionnaire

    Information required for preparing your application in the IRCC Portal and the Basis of Asylum Claim

    15 sections · Complete all applicable sections

    1. Passport
    2. Brown paper
    3. Personal
    4. Contact details
    5. Address
    6. Language
    7. Documents
    8. Matrimonial
    9. Family
    10. Travel
    11. Education/Employment
    12. Judicial
    13. Medical
    14. Travel history
    15. Asylum application

    1

    Information recorded in the passport

    Identity as it appears on your primary passport

    🛂

    First Name *

    Last Name *

    Date of Birth *

    Sex

    MaleFemale

    Passport Number

    Issuing Country

    Issue Date

    Expiration Date

    Location where this document is kept

    2

    Identity Document — “Brown Paper”

    Complete only if you have this document or if you filed your claim at a port of entry

    📄

    IUC Number

    Application No. (starts with L)

    Nationality

    City and Country of Birth

    Other Nationalities

    Acquisition method (birth, marriage, etc.)

    3

    Personal Data

    Physical characteristics and names used

    👤

    Height (cm or inches)

    Eye Colour

    Have you ever used other names?

    YesNo

    If yes, please specify:

    4

    Contact Details in Canada

    Current residential and mailing address in Canada

    🏠

    Residential Address

    Building No.

    Street

    Apt. No.

    City

    Province

    Postal Code

    Phone Number *

    Email *

    At this address since

    Mailing address same as residential?

    YesNo

    Mailing Address (if different)

    Building No.

    Street

    City

    Province

    Postal Code

    5

    Addresses (Last 10 Years)

    Start with the most recent — do not leave any period uncovered

    📍

    Start (YYYY-MM)

    End (YYYY-MM)

    Status in this country

    Address

    City

    Country

    6

    Language

    Native language and communication preferences

    🗣️

    Native Language

    Other languages or dialects

    Preferred language for communications

    FrenchEnglish

    Interpreter language (N/A if not applicable)

    7

    Travel and Identity Documents

    Additional passport and identity card

    🗂️

    Additional Passport

    Do you have another passport not presented to immigration?

    YesNo

    Number (if yes)

    Issuing Country

    Issue Date

    Expiration Date

    Identity Card

    Do you have an identity card?

    YesNo

    Number (if yes)

    Issuing Country

    Issue Date

    Expiration Date

    8

    Marital Status

    Current marital situation and partner information

    💍

    Current Marital Status

    Never marriedMarriedCommon-law partnerDivorcedSeparatedWidowed

    Date of current status

    Partner’s Last Name

    Partner’s First Name

    Partner’s Date of Birth

    Partner’s Address

    9

    Family Information

    Father, mother, spouse, biological/adopted children, brothers and sisters

    👨‍👩‍👧‍👦

    Relationship

    Last Name

    First Name

    Date of Birth

    Country of Birth

    Current Address

    If deceased: place and date

    Are any children under 18 claiming asylum with you?

    YesNo

    If yes — describe the situation (parent, documents, consent):

    10

    Travel Steps to Canada

    Chronological order — do not leave any period uncovered

    ✈️

    #

    Departure Date

    Departure City/Country

    Mode

    Arrival Date

    Arrival City/Country

    1

    2

    3

    4

    11

    Education and Employment

    Post-secondary education and employment history for the last 10 years

    🎓

    Post-Secondary Education

    Have you studied at a post-secondary institution?

    YesNo

    Start

    End

    Institution

    City, Country

    Level

    Field

    Diploma

    Employment (Last 10 Years)

    Start

    End

    Job Title

    Company / Organization

    Address

    Have you worked for a government administration?

    YesNo

    If yes — details:

    Have you been part of the military, militia or police?

    YesNo

    If yes — details:

    12

    Criminal History

    Answer honestly — all answers are confidential

    ⚖️

    Have you been convicted of a crime?

    YesNo

    Have you been arrested for a criminal offence?

    YesNo

    Have you been charged or wanted for a crime?

    YesNo

    Have you committed a crime (including impaired driving)?

    YesNo

    Have you supported or been a member of any organizations?

    YesNo

    Have you supported organizations advocating armed violence?

    YesNo

    Have you been a member of a criminal organization?

    YesNo

    Have you witnessed mistreatment of prisoners or civilians?

    YesNo

    Have you used or advocated violence for political/social/religious purposes?

    YesNo

    13

    Medical History

    Current or past medical conditions

    🏥

    Have you suffered from a physical or mental illness?

    YesNo

    Do you have any current infectious diseases? If yes, specify:

    YesNo

    14

    Travel History and Visas

    Travel over the last 10 years, Canadian and US visas, and family in Canada

    🌍

    Travel History (Last 10 Years)

    Start (YYYY-MM)

    End (YYYY-MM)

    City, Country

    Purpose of travel

    Status in this country

    Has any country refused you a visa, deemed you inadmissible, or ordered you to leave?

    YesNo

    Canadian and US Visas

    Are you a US permanent resident (green card)?

    YesNo

    Canadian visitor visa (last 10 years)?

    YesNo

    US non-immigrant visa?

    YesNo

    Family in Canada

    Do you have family in Canada?

    YesNo

    Relationship

    First Name

    Last Name

    Sex

    Date of Birth

    Address

    Person Who Helped You Come to Canada

    Did someone help you come to Canada?

    YesNo

    Full Name (helper)

    Address (helper)

    Email (helper)

    Phone (helper)

    Relationship (family, friend, professional)

    Preferences and Visa Application

    Preferred interview location

    MontrealTorontoVancouver

    Request a work permit?

    YesNo

    Accommodations required?

    YesNo

    Have you applied for a Canadian visa?

    YesNo

    Visa type

    Issue Date

    Refusal Date

    Reasons for refusal

    15

    Asylum Application — Grounds

    Answer in detail: What, When, Who, Why, How. Include dates, names and locations.

    🛡️

    1. Harm, mistreatment or threats suffered (by you or your family)

    2. Why are you unwilling or unable to return to your country?

    3. If you returned, what would happen to you, who would be responsible and why?

    4. Did you ask the authorities (police, etc.) for protection? Explain.

    5. Did you relocate to another part of your country to seek safety?

    6. When did you leave your country?

    7. Why at that time and not sooner or later?

    8. Did you seek refuge in another country (other than Canada)? Country, dates, duration, asylum claim?

    9. If you did not claim asylum upon arrival in Canada, why not?

    10. Why did you choose Canada rather than another country?

    11. Have you ever made an asylum claim in Canada, in another country, or with the UNHCR?

    12. If a child aged 6 or under is claiming asylum with you, explain why they would be at risk of harm.

    13. Any other important details in support of your asylum claim

    Previous Asylum Claims (you or your family)

    Last Name

    First Name(s)

    Relationship

    Date of claim

    Country or UNHCR

    Outcome

    IRB file No. / IRCC ID

    By submitting this form, you confirm that all information provided is accurate and complete.

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