BSF814 - Pilot Project for Travellers In Remote Areas - Quebec (PPTRA-Q) Application Form

Protected B when completed

Please type or print
We will not accept incomplete applications.

1. Preferred language - English / French
2. What is your main reason for applying? Pleasure / Work

Section A – Personal Information

3. Last name
4. First name
5. Middle name
6. Other last names used (e.g., maiden name, former name)
7. Other first names (nickname)
8. Gender (Male / Female)
9. Date of birth YYYY MM DD
10. Place of birth - City
11. Province/State
12. Country
13. Citizenship (Canadian citizen / U.S. citizen / Other (please specify))
14. Residence (Canada / United States / Other (please specify))
15. Proof of citizenship/residency/immigration status (check all that apply). A photocopy of the document(s) must be attached.
    • Birth certificate no.
    • Passport no. - Country of issuance - YYYY MM DD (Expiry date)
    • Citizenship card no.
    • Permanent resident document no.
    • U.S. alien registration no. - YYYY MM DD (Expiry date)
    • Other (Type of document / No.)

Section B – Address history for the last five years

16. Current address since: Year, Month
17. Street address
18. Apt.
19. City
20. Province/State
21. Postal/Zip code
22. Country
23. Home telephone
24. Business telephone
25. Cellular telephone
26. Email address

Mailing address if different from residential address

27. Street address
28. Apt.
29. City
30. Province/State
31. Postal/Zip code
32. Country

Previous residential addresses if you have been at your current residence for less than five years (attach a separate sheet if necessary).

33. From: Year, Month
    To: Year, Month
34. Street address
35. Apt.
36. City
37. Province/State
38. Postal/Zip code
39. Country

Section C - Employment history for the last five years

40. Current employer since: Year, Month
41. Employer's name
42. Street address
43. City
44. Province/State
45. Postal/Zip code
46. Country
47. Telephone number Ext.
48. If self-employed, please specify type of business:
49. Other (please specify)

Previous employer's name and addresses if you have been with your current employer for less than five years (attach a separate sheet if necessary).

50. From: Year, Month
    To: Year, Month
51. Employer's name
52. Street address
53. City
54. Province/State
55. Postal/Zip code
56. Country

Section D - This section must be completed by all non-Canadian citizens and all non-Canadian permanent residents

57. What is the purpose of your travel to Canada? (check all applicable boxes)
    • Pleasure
    • Business/Work
    • Study
    • Other (specify)

Attached is a copy of my employment/student authorization issued by: (Canada / U.S.) Expiry date YYYY MM DD

If the purpose of your travel to Canada will be for business, work, or study, you may have to obtain written authorization from Immigration, Refugees and Citizenship Canada (IRCC) before joining the program. Contact a IRCC office in Canada or any Canadian consular office abroad.

Section E - Additional Information

58. Have you ever been:
    • Found in violation of any customs legislation? Yes / No
    • Found in violation of any immigration legislation? Yes / No
    • Convicted of an offence in Canada for which a pardon or rehabilitation has not be granted? Yes / No
    
    If you answered "Yes" to any of these questions, please provide details (use separate sheet if necessary).

Section F - Fee payment (non-refundable) – No fee required for applicants under 18 years of age

• CAN $50 per applicant
• I am enclosing a certified cheque or money order payable to the Receiver General for Canada.
• Cardholder's name (please print)
• Cardholder's signature

If paying with a credit card you must include a phone number where you can be reached during business hours. The Canadian Processing Centre will contact you at the number provided to obtain your payment information. Please note that your application will not be processed until payment has been confirmed. We ask that you keep a copy of this application for reference.

• I choose to pay using my credit card and I consent to being contact by the Canadian Processing Centre.

Section G - Non-custodial parent or legal guardian

The person applying on behalf of a child under 18 years of age must either be the parent or the person who has custody or tutorship of the child under a court order if every parent and every other person who has custody or tutorship consent to the application. As such, documents such as a letter of consent from the other parent and other person who has custody or tutorship is required. In addition, a court document stating the custodial or tutorship agreement must be provided so that custody/tutorship can be verified as well as that there are no restrictions on removal from the custodial/tutorship jurisdiction

Section H - Certification

I certify that all information given on this application, and in support of this application, is provided voluntarily and is true, accurate and complete.

I certify that I have read, understood, and agree to abide by all conditions applicable to the program to which I apply, and to the use of the associated authorization, including all instructions and notices accompanying this application

Signature of applicant or signature of parent or legal guardian if applicant is under the age of 18:

• Name (print)
• Signature
• Date

Privacy Statement

The information you provide in your application, including supporting documentation, is collected by the Canada Border Services Agency (CBSA) and is protected pursuant to both the Customs Act and the Privacy Act. In accordance with Canadian laws and regulations, this information will be shared with other government departments or agencies in Canada for the purpose of the operation of the Pilot Project for Travellers in Remote Areas - Quebec (PPTRA-Q) program, and to conduct applicable checks and verifications to determine your eligibility and continued eligibility in the PPTRA-Q program. If the required information is not provided, your application may not be processed and the authorization may not be granted.

Information collected for the purpose of the operation of the PPTRA-Q may also be disclosed within the CBSA and to other government departments or agencies (including the Royal Canadian Mounted Police and the Canadian Security Intelligence Service) for their use, in accordance with section 107 of the Customs Act.

Individuals to whom the information relates have rights to, correction of and protection of, their personal information under the Privacy Act. The collection, use, disclosure and retention of your personal information is described in Personal Information Bank CBSA PPU 002. Instructions for obtaining information are provided the CBSA’s Information about Programs and Information Holdings (formely Info Source), which is available at public libraries, government public reading rooms and on the Internet.

Individuals to whom the information relates also have the right to file a complaint to the Privacy Commissioner of Canada should they have a concern about how the CBSA handles their information. Instructions for filing a privacy complaint.

Consent

I understand that any information gathered for the purposes of this application, including any supporting documentation or background information, as well as information obtained from the relevant files of law enforcement agencies, including intelligence gathered for law enforcement purposes, will be to conduct applicable checks and verifications to determine eligibility and continued eligibility in the PPTRA-Q program as described on the website, and that this information as well as my photograph will be used for the purpose of the operationo of the PPTRA-Q. My contact information may also be used by the CBSA to send me notifications related to changes to the PPTRA-Q program.

If you do not consent to the above noted collection, use and sharing of your personal information, your application cannot be processed and an authorization cannot be granted.

Do you consent to the above noted collection, use, and sharing of your personal information? Yes / No

For office use only

Payment

• Amount
• Initials
• Date

Please submit your completed application along with your CAN $50 application fee to the following address:

Canadian Processing Centre
400 Place d'Youville
Montreal, QC
H2Y 2C2
Telephone: 1-866-399-5887

Date modified:

2022-07-14