Will accompany

you to Canada?

Full name

APPLICANT

Full name

(DISPONIBLE EN FRANAIS - IMM 5645 F)

FAMILY INFORMATION

IMM 5645 (09-2010) E

Citizenship andImmigration Canada

Citoyennet etImmigration Canada

BEFORE YOU START, READ THE INSTRUCTION GUIDE, TYPE OR PRINT IN BLACK INK.SECTION A

PROTECTED WHEN COMPLETED - BPAGE 1 OF 2

Date of birth

Complete ALL names in English and in your native language (for example, Arabic, Cyrillic, Chinese, Chinese commercial/telegraphic code, Korean, or Japanesecharacters). Include ALL family members even if they are not accompanying you. If you need more space for any section, print out an additional page containingthe appropriate section, complete and submit it with your application.

SPOUSE ORCOMMON-LAW

PARTNER

MOTHER

FATHER

RelationshipSEE NOTE 1 Country

of birthPresent occupation

Present address(If deceased give city and date)

Marital statusY M D

NOTE 1: If no spouse or common-law partner is listed in Section A, read and sign below.

I certify that I do not have a spouse or a common-law partner.

SECTION B CHILDREN (Include ALL sons and daughters, including ALL adopted and step-children, regardless of age or place of residence)Date of birth

RelationshipSEE NOTE 2 Country

of birth

Will accompany

you to Canada?Present occupation

Present address(If deceased give city and date)

Marital statusY M D

NOTE 2: If no children are listed in Section B, read and sign below.

I certify that I do not have any children, either natural or adopted.

Type of application: Visitor Worker Student Other

YES NO

YES NO

Date:

DayYear Month

Signature:

Date:

DayYear Month

Signature:

IMM 5645 (09-2010) E

The information you provide on this form is collected under the authority of the Immigration and Refugee Protection Act to determine if you may be admitted to Canada as a temporaryresident. It will be stored in Personal Information Bank CIC PPU 055, Visitor Case File. It is protected and accessible under the Privacy Act and the Access to Information Act.

I certify that the information contained on this document is complete, accurate and factual. I also realize that once this document has been completed andsigned that it will form part of my Immigration Record and will be used to verify my family details on future applications.

SECTION D CERTIFICATION

PAGE 2 OF 2

Full name

SECTION C BROTHERS AND SISTERS (Include ALL brothers and sisters, ALL half-brother and sister and stepbrother and sister.)Date of birth

RelationshipCountryof birth

Will accompany

you to Canada?Present occupation

Present address(If deceased give city and date)

Marital statusY M D

YES NO

Date:DayYear Month

Signature:

app_type: visitorAname: 0: Sara Gabriela Llanos Roman1: 3: Danilo Atilio Llanos Curletti 2: Donatila Azucena Roman Aliaga de LlanosAdateY: 0: 19861: 2: 19553: 1949AdateM: 0: 051: 2: 013: 03AdateD: 0: 081: 2: 123: 26Acob: 0: Peru1: 2: Peru3: PeruAstatus: 0: single1: 2: married3: marriedAadd: 0: 551 Maximo Abril Street dpto 1702 Jesus Maria Lima Peru1: 2: 551 Maximo Abril Street dpto 1702 Jesus Maria Lima Peru3: 551 Maximo Abril Street dpto 1702 Jesus Maria Lima PeruAocc: 0: Business Development manager1: 2: Teacher3: Business manAacc: 1: Off2: no3: noBname: 1: 2: 3: 4: 5: 0: BdateY: 1: 2: 3: 4: 5: 0: BdateM: 1: 2: 3: 4: 5: 0: BdateD: 1: 2: 3: 4: 5: 0: Bcob: 1: 2: 3: 4: 5: 0: Bstatus: 1: 2: 3: 4: 5: 0: Badd: 1: 2: 3: 4: 5: 0: Bocc: 1: 2: 3: 4: 5: 0: Bacc: 0: Off1: Off2: Off3: Off4: Off5: OffBrelation: 1: 2: 3: 5: 0: 4: AsigDateY: AsigDateM: AsigDateD: Cname: 0: Danilo Julio Llanos Roman1: Ana Liz Llanos Roman2: 3: 4: 5: 6: Crelation: 0: brother1: sister2: 3: 4: 5: 6: CdateY: 0: 19821: 19832: 3: 4: 5: 6: Ccob: 0: Peru1: Peru2: 3: 4: 5: 6: CdateM: 0: 121: 092: 3: 4: 5: 6: CdateD: 0: 081: 052: 3: 4: 5: 6: Cstatus: 0: single1: single2: 3: 4: 5: 6: Cocc: 0: HSE leader at Talisman Peru1: ANANDRA Urban Clothes general manager2: 3: 4: 5: 6: Cadd: 0: 551 Maximo Abril Street dpto 1702 Jesus Maria Lima Peru1: 551 Maximo Abril Street dpto 1702 Jesus Maria Lima Peru2: 3: 4: 5: 6: Cacc: 0: no1: no2: Off3: Off4: Off5: Off6: OffBsigDateY: BsigDateM: BsigDateD: CsigDateY: DsigDateM: DsigDateD: