¡*t ,?*iü:!ll"T!",0" fl',x€,.:li# Bln.ou pRorEcrED wHEN coMpLErED - B PAGE 1 OF 2 FAMILY INFORMATION Type of application: lZ vi.itor l-l worter fl Stuoent I o,1", Complete ALL names in English and in your native language (for example, Arabic, Cyrillic, Chinese, Chinese commercial/telegraphic code, Korean, or Japanese characters). lnclude ALL family members even if they are not accompanying you. lf you need more space for any section, print out an additional page conta¡ning the appropriate section, complete and submit il wilh your application. BEFORE YOU START, READ THE INSTRUCTION GUIDE, TYPE OR PRINT IN BLACK INK. SECTION A Full name Relationship SEE NOTE 1 Date of birth YfuID l\,4arital status Present address (lf deceased give city and date) will accompany you to Canada? YES NO Country of birth Present occupation Ana Liz Llanos Román APPLICANT 1983 09 0s síngle 551 lVaximo Abril Street dpto 1702 Jesus i\,4aria Lima peru )erú ANANDRA Urban Clothes general manager SPOUSE OR COMMON.LAW PARTNER TN Donatila Azucena Roman AIiaga de Llanos MOTHER 1955 01 12 márr¡ed 551 l\,4aximo Abril Street dpto 1702 Jesus lvlaria Lima peru TZ Peru Teacher lanilo Atilio Llanos Curleiti FATHER 1949 03 26 marr¡ed 551 iVaximo Abril Street dpio 1702 Jesus lvlaria Lima peru ng Peru Businness man NOTE 1: lf no spouse or common-law partner is listed in Section A, read and sign below. I certiñ/ that I do not have a spouse or a common-law partner. ) S¡gnature: Date: SECTION B CHILDRE¡¡ (lnclude ALL sons and daughters, including ALL adopied and step-ch¡ldren, regardless of age or place of residence) Full name Relationsh¡p SEE NOTE 2 Date of b¡rth Y]!1 D lvlarital status Present address (lf deceased g¡vé c¡ty and date) W¡II accompany you 1o Canada? YES NO Country of b¡rth Present occupation rn TN [[ TT IT ur NOTE 2: lf no children are listed in Section B, read and sign below. I certify that I do not have any children, either natural or adopted. ) Signature: Date: Canad'á t' 6 ltvtM 5645 109-2010) E (DrsPoNrBLE EN FRAN9ATS - rMM s645 F)

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¡*t ,?*iü:!ll"T!",0" fl',x€,.:li# Bln.ou pRorEcrED wHEN coMpLErED - B

PAGE 1 OF 2

FAMILY INFORMATION

Type of application: lZ vi.itor l-l worter fl Stuoent I o,1",

Complete ALL names in English and in your native language (for example, Arabic, Cyrillic, Chinese, Chinese commercial/telegraphic code, Korean, or Japanesecharacters). lnclude ALL family members even if they are not accompanying you. lf you need more space for any section, print out an additional page conta¡ningthe appropriate section, complete and submit il wilh your application.BEFORE YOU START, READ THE INSTRUCTION GUIDE, TYPE OR PRINT IN BLACK INK.SECTION A

Full name RelationshipSEE NOTE 1

Date of birthYfuID

l\,4arital status

Present address(lf deceased give city and date)

willaccompany

you to Canada?YES NO

Countryof birth

Present occupation

Ana Liz Llanos Román

APPLICANT

1983 09 0ssíngle 551 lVaximo Abril Street dpto 1702 Jesus i\,4aria Lima peru

)erúANANDRA Urban Clothes general manager

SPOUSE ORCOMMON.LAW

PARTNER TNDonatila Azucena Roman AIiaga deLlanos

MOTHER

1955 01 12márr¡ed 551 l\,4aximo Abril Street dpto 1702 Jesus lvlaria Lima peru

TZPeruTeacher

lanilo Atilio Llanos Curleiti

FATHER

1949 03 26marr¡ed 551 iVaximo Abril Street dpio 1702 Jesus lvlaria Lima peru

ngPeruBusinness man

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

I certiñ/ that I do not have a spouse or a common-law partner. ) S¡gnature: Date:

SECTION B CHILDRE¡¡ (lnclude ALL sons and daughters, including ALL adopied and step-ch¡ldren, regardless of age or place of residence)

Full name Relationsh¡pSEE NOTE 2

Date of b¡rth

Y]!1 Dlvlarital status

Present address(lf deceased g¡vé c¡ty and date)

W¡IIaccompany

you 1o Canada?

YES NO

Countryof b¡rth

Present occupation

rnTN

[[

urNOTE 2: lf no children are listed in Section B, read and sign below.

I certify that I do not have any children, either natural or adopted. ) Signature: Date:

Canad'át'

ltvtM 5645 109-2010) E (DrsPoNrBLE EN FRAN9ATS - rMM s645 F)

{'11

SECT]ON C

SECTIOND CERTIFICATION

BROTHERS AND SISTERS (lnclude ALL brothers and sisters, ALL hálf-brother and s¡ster and

PAGE 2 OF 2

Date of birthYJlI D Marital status

wi¡laccompany

you to Canada?

YES NO

Gabriela Llanos Roman Leslie Street 445 M4M 3E5 Toronto

1982 08'12Avenue dpto 201 San ls¡dro Lima

lcertifythattheinformationconta¡nedonthiSdocumentiscomplete,accr*ateancfactual.|alSoreatizetnátonsigned that ii will form part of my lmmigrat¡on aecofiVn| will be used to veri¡/ my fam¡ly details on future appiiáions.

t--*-';m;lDatei | 291: q6 | 25

f he rnformation you provide on lhis form is collected under the authority of ihe tmm¡grat¡on and Refugee Protectian Act lo determine if you may be admitted to Canada as a temporarresid¿'rl li wiil be stored in Personal lnÍormation Bank CIC PPU 055, vísitor Case File. lt is protected anc eccessible under the Privacy ,Act and the Access to lnformatjon Act.

llv]M 5645 (09-2010) E