Waiver Questions

7) Mother's Full Name Before Marriage: (Full Maiden Name Given at Birth)
8) Mother's Date of Birth: ie: July 10, 1942
9) Mother's City, Province & Country of Birth:
10) Mother's City & Country of Residence (if living):

11) Spouse's Full Maiden Name: (Full Maiden Name Given at Birth)
12) Spouse's Date of Birth:: ie: June 21, 1968
13) Spouse's City, Province & Country of Birth:
14) Date of Marriage: ie: July 30, 1990
15) Place of Marriage:

16) Ex-Spouse Information:

Full Maiden Name:
Date of Birth:
Date of Marriage:
Place of Marriage:
Date Marriage Terminated
Place Marriage Terminated:

17) When Did You Move to Your Present Address? (month & year):

17A) List any previous addresses in the last 5 Years that you did not list on the first application, including the move-in & move-out Month and Year:

( Postal Codes are required )

Employment History for Last 5 Years

18) Full Name of Present Employer:
18A) Full Address of Present Employer: ( Postal Codes are required )
18B) Date Started: (month & year)
18C) Occupation:

19) Full Name of Previous Employer:
19A) Full Address of Previous Employer:
19B) Date Started & Ended: (month & year) to (month & year)
19C) Occupation:

20) Full Name of Previous Employer:
21A) Address of Previous Employer:
21B) Date Started & Ended: (month & year) to (month & year)
21C) Occupation:

21) Full Name of Previous Employer:
21A) Address of Previous Employer:
21B) Date Started & Ended: (month & year to month & year)
21C) Occupation:

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22) Main Purpose(s) for Entering the U.S.:
23) Maximum Amount of Time You Plan to Stay:
24) Most Common Method of Travel: (airline, auto, cruise ship, etc.)
25) Most Frequent or Desired Port of Entry: (city airport or border name)

26) Have you ever stayed in the U.S. for longer than 6 months?

Yes (if Yes (if Yes please enter details about the offense in the Additional Comments section below)

No

27) Have you ever filed an application or petition for immigration or US Government benefits, or has one ever been filed on your behalf? (includes Work Visa, Student Visa, Green Card, Temporary Resident Permit, Nexus, FAST Card, etc.)

Yes (if Yes (if Yes please enter details about the offense in the Additional Comments section below)

No

28) Have you ever been denied or refused an immigration or US Government benefit, or had one revoked or terminated?

Yes (if Yes (if Yes please enter details about the offense in the Additional Comments section below)

No

29) Have you ever been arrested, cited, charged, indicted, fined or imprisoned in the U.S. for breaking or violating any law, NOT including traffic violations?

Yes (if Yes please enter details about the offense in the Additional Comments section below)

No

30) What is your A-Number? (For past Waiver applicants only - File Number on Waiver Certificate)

31) What is your U.S. Gov't issued Social Security Number? (Not Canadian Gov't issued Social Insurance Number)

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Note: If you obtained a Waiver Certificate in the past please fax or email a copy of it to our office ASAP if we do not already have a copy.

Fax: 780-665-7371, email: mail@canadapardonsanduswaivers.com

Additional Comments:

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