Professional Documents
Culture Documents
Imm5406e Final - PDF Family
Imm5406e Final - PDF Family
BEFORE YOU START, READ THE INSTRUCTION GUIDE. TYPE or PRINT in black ink.
SECTION A
Date of birth Marital
Name Relationship Place of birth Present address
(YYYY-MM-DD) status
married
Angela Khodorkovski Applicant 1992-07-13 Edmonton, AB
physic
5831 205 St NW Edmonton, AB T6M 2Z5
Elena Konikov Mother 1963-12-30 Tula, USSR married Mivtza Moshe 4/3 Beer Sheva, Israel
Viatcheslav Konnikov
Father 1966-05-25 Vitsyebk, USSR married Mivtza Moshe 4/3 Beer Sheva, Israel
SECTION B CHILDREN (Include ALL sons and daughters, including ALL adopted and step-children, regardless of age or place of residence)
Date of birth Marital Present address and
Name Relationship Place of birth
(YYYY-MM-DD) status e-mail address
E-mail address
E-mail address
E-mail address
E-mail address
SECTION C BROTHERS AND SISTERS (Including half - and step-brothers and sisters)
Date of birth Marital
Name Relationship Place of birth Present address
(YYYY-MM-DD) status
Emilia Konikov Sister 1987-06-06 Crimea, USSR married Mivtza Moshe 4/3 Beer Sheva, Israel
SECTION D CERTIFICATION
I certify that the information contained on this document is complete, accurate and factual. I also realize that once this document has been completed and signed that it will form part of
my Immigration Record and will be used to verify my family details on future applications.
The information you provide is collected under the authority of the Immigration and Refugee Protection Act to determine if you may be admitted to Canada as an immigrant. It will be
stored in Personal Information Bank number EIC PPU 015. It is protected and accessible under the provisions of the Privacy Act and the Access to Information Act.