Citizenship and Citoyenneté et PAGE 1 OF 6

Immigration Canada Immigration Canada

FOR OFFICIAL USE ONLY
Receipt no.

APPLICATION TO File no.

UCI no.
RESUME CANADIAN
CITIZENSHIP Claim Loss

Under Subsection 11(1) Date of loss D M Y

and for
PERSONS WHO LOST Loss confirmed by:
Signature Date
CITIZENSHIP AS MINORS D M Y

Under Subsection 11(1.1)

Certificate no.

Before you start, read the instructions

Please PRINT in ink or TYPE Protected when completed
For official use only
1 I am applying for resumption of Canadian
citizenship under Subsection 11(1)
I am applying for resumption of Canadian
citizenship under Subsection 11(1.1) Please check ( ) one
(lost as a minor under the 1947 Act)

2 I want service in English OR French Please check ( ) one

3 I have special needs No Yes If yes, explain:

Day Month Year

4 Have you applied to
resume citizenship
No Yes Date

before?

Have you ever had No Yes If yes, give information that appears on the certificate.
a certificate of
Canadian Family name
citizenship?

Given name(s)

Certificate no. Date

Day Month Year

previously
My certificate was/is: attached stolen lost destroyed
returned

Was the theft/loss

No Yes Details
reported to police?

Note : It is illegal to have more than one valid certificate of citizenship or naturalization. If you have any certificate
of citizenship or naturalization or any pink transmission copy of a certificate, you have to send it back.

5A Name (If applying within Canada use name exactly as shown on immigration document. If applying from outside Canada, please see appendix A.)
Family name

Given name(s)

B Legal name Family name

change since No If yes, provide legal name To:
Yes
the name change document.
provided in 5A Given name(s)

C Other names Family name D Name you want Family name

used (example on citizenship
maiden name certificate
or name at Given name(s) (documentation Given name(s)
birth) required)

Use another piece of paper if you need more space.

(AUSSI DISPONIBLE EN FRANÇAIS - CIT 0301 F)

CIT 0301 (03-2006) E AVAILABLE ON CIC WEB SITE AT: http://www.cic.gc.ca
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6 A Birth details Date

Day Month Year
Place
City, town, etc. Country

B Personal Male OR Colour

Sex Female Height cm OR ft in
of eyes
information

C Marital status Single Married Common-law Widowed Divorced Separated

7 A Home address

Postal code

B Mailing address
(if different from
home address) Postal code

C Telephone number(s) Home ( ) Work ( ) Ext. Cellular ( )

D I have lived at this address year(s) and month(s)

8 A Are you a citizen of any other countries?

No Yes If yes, please list the date(s), country (countries) and how you obtained this citizenship.

FROM TO
D M Y D M Y What country? How did you obtain this citizenship?

Use another piece of paper if you need more space.

B If you received a Canadian citizenship certificate before February 15, 1977 OR you have never had a Canadian citizenship certificate please list absences from Canada
for 1 year or longer before 1977.
FROM TO DESTINATION REASON
D M Y D M Y What country did you go to? Why did you go to this country?

Use another piece of paper if you need more space.

C Are you a permanent resident of Canada?

Day Month Year
Yes No If yes, indicate the date you became a permanent resident.

If you are applying using subsection 11(1.1), sections 8D, 8E, 8F and 8G do not apply to you. Go to section 9.

Day Month Year

D When did you return to Canada if different from 8C?

E Did you obtain permanent residence in another country since becoming a permanent resident of Canada?

No Yes If yes, please list the country (countries).

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F Have you left Canada in the last year?

No Yes If yes, please list all of your trips outside Canada (including vacations and all trips to the United States) in the last year.

FROM TO TOTAL
DESTINATION REASON FOR ABSENCE
D M Y D M Y # DAYS

Use another piece of paper if you need more space. TOTAL

G List all of your addresses (including foreign addresses) in the last year.

FROM TO
ADDRESS CITY, PROVINCE, COUNTRY
M Y M Y

Use another piece of paper if you need more space.

9 PROHIBITIONS UNDER THE CITIZENSHIP ACT

1. Are you now or have you ever been in the last year:
• an inmate of a penitentiary, jail, reformatory, or prison?
• on probation?
• on parole?

2. In the past 3 years, have you been convicted of an indictable offence (crime) in Canada or an offence under the Citizenship Act?

3. Are you now charged with an offence (crime) or an offence under the Citizenship Act?

4. Are you now, or have you ever been, under a removal order (have you been asked by Immigration officials to leave Canada)?

5. Are you now under investigation for, or charged with, a war crime or a crime against humanity or have you ever been convicted
of a war crime or a crime against humanity?

6. In the past 5 years, have you had Canadian citizenship which has been taken away (revoked)?

I have read and understand the prohibitions under the Citizenship Act. I declare that these prohibitions:

Do not apply to me. Do apply to me. Provide details:

10 A Were you born outside Canada No Yes

to a Canadian parent?

B Were you a British subject

No
If yes, on what date did you Day Month Year
Yes
living in Canada before 1947? enter Canada to live?

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11 APPLICANT'S PARENTS
Answer all of the following questions:

Relationship to you Natural father Adoptive father Natural mother Adoptive mother

FATHER MOTHER
Maiden name
Family name

Given name(s)

Day Month Year Day Month Year

Country and date of birth

Day Month Year

Married in what country Date of marriage

How did he obtain Canadian citizenship? How did she obtain Canadian citizenship?
Additional information

Did he leave Canada for more than 1 year before 1977? Did she leave Canada for more than 1 year before 1977?

No Yes No Yes

From To From To
M Y M Y Destination (Country) M Y M Y Destination (Country)

Is he or was he a citizen of a country other than Canada? Is she or was she a citizen of a country other than Canada?
Give details Give details
No Yes (country, date and how No Yes (country, date and how
citizenship was obtained) citizenship was obtained)

Was he employed in Canada by a foreign government or Was she employed in Canada by a foreign government or
international agency? international agency?

No Yes Give details No Yes Give details

If father was born in Canada, was one of his parents If mother was born in Canada, was one of her parents
employed by a foreign government or international agency? employed by a foreign government or international agency?

No Yes Give details No Yes Give details

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12 If you are applying using subsection 11(1.1), section 12 does not apply to you. Go to section 13.
If you are a woman and married before January 1, 1947, answer the following questions.
If you married for the first time on or after January 1, 1947, this question does not apply to you. Go to Section 13.

Information on Husband's family name

your husband
(Provide details of every
marriage before 1947.) Given name(s)

Day Month Year

Husband's country of birth Date of birth

Day Month Year

Country of marriage Date of marriage

Is your husband a Canadian citizen? No Yes by birth OR other

Number on husband's citizenship certificat Day Month Year

Date
(if applicable)
Please use another piece of paper if you need more space to list other marriages.

13 CONSENT TO DISCLOSE PERSONAL INFORMATION

If you are not a resident of Canada, section 13 does not apply to you. Go to section 14.

CONGRATULATORY LETTER:
Request for authorization

Federal Members of Parliament (M.P.s) send a letter of congratulations to new citizens in their ridings. Do you authorize Citizenship and Immigration Canada to
forward your name, address and preferred official language to your Member of Parliament? No other information will be forwarded.

Yes No

This information will be disclosed once your Canadian citizenship is resumed.

14 CONSENT TO DISCLOSE PERSONAL INFORMATION

A NATIONAL REGISTER OF ELECTORS:

Request for authorization

Canadian citizens who are 18 years of age or older have the right to vote in federal elections and referendums.

Elections Canada needs your authorization to add your name to the National Register of Electors to ensure that you are included on the list of electors for
federal elections and referendums.

Do you authorize Citizenship and Immigration Canada to forward your name, address, gender and date of
Yes No
birth to Elections Canada so that this information can be added to the National Register of Electors?

No information will be forwarded to Elections Canada until you resume Canadian citizenship. By law this information will be used for electoral purposes only.

For more information, please refer to Section 14 of "How to Complete Your Application".

B QUÉBEC'S PERMANENT LIST OF ELECTORS:

Request for authorization

To make sure that you are on the list of electors for provincial, municipal or school elections, the Chief Electoral Officer of Québec needs to add your name
to Québec's Permanent list of electors.

Do you authorize Citizenship and Immigration Canada to forward your name, address, gender and date of
Yes No
birth to the Chief Electoral Officer of Québec so that this information can be added to the permanent list?

No information will be forwarded until you resume Canadian citizenship. By law this information will be used for electoral purposes only.

For more information, please refer to Section 14 of "How to Complete Your Application".

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15 SIGNATURE OF APPLICANT
I agree to advise Citizenship and Immigration Canada if any information on this form changes before the processing of my application is complete. I understand the contents
of this form. I declare that the information provided is true, correct, and complete, and that the photographs enclosed are a true likeness of me. I understand that if I make a
false declaration, or fail to disclose all information material to my application, I could lose my Canadian citizenship and be charged under the Citizenship Act.
I have indicated in Section 9 whether the prohibitions apply to me.

Day Month Year

Signature of APPLICANT Place Date

IMPORTANT NOTE:
Remember to make sure that you are eligible to apply for citizenship on the day before you SIGN this application.

16 INDIVIDUAL, FIRM OR ORGANIZATION WHO ASSISTED IN THE COMPLETION OF THIS APPLICATION

(The applicant does not complete this section)

Name of individual who assisted in

completing this application form:

Name of firm, organization:

Address:

Day Month Year

Signature of INDIVIDUAL Date

REMEMBER:

If you are sending more than one application, send all of them together in one envelope.
The applications will be processed together.

FAILURE TO INCLUDE THE NECESSARY DOCUMENTATION (e.g. 2 PIECES OF IDENTIFICATION)

WILL RESULT IN DELAYS IN PROCESSING YOUR APPLICATION.

Protected Information
Personal Information Bank CIC PPU 050
The information you provided on this form is collected under the authority of the Citizenship Act and will be used to determine eligibility for the grant of Canadian citizenship according
to the requirements of the Act, and to maintain a record of persons to whom citizenship certificates were issued. It will be retained in the Personal Information Bank CIC PPU 050. It
may be shared with other organizations in accordance with the consistent use of information under the Privacy Act. Under the Privacy Act and the Access to Information Act
individuals have the right to protection of and access to their personal information. Details on these matters are available at infosource.gc.ca and through the Citizenship and
Immigration Canada Call Centre. Infosource is also available at Public Libraries in Canada.

CIT 0301 (03-2006) E