Application for Selection Certificate – Individual in particular crisis situation –

Application for Selection Certificate – Individual in particular crisis situation –
Protected person on-site and family members
WHY COMPLETE AN APPLICATION FOR QUÉBEC SELECTION CERTIFICATE?
As a Convention refugee or protected person, you now have access to a wider assortment of services provided by the Québec government,
including full-time francization services and healthcare coverage provided by the Régie de l’assurance maladie du Québec. In order to be
entitled to receive these services, you must present your « Certificat de sélection du Québec » (CSQ) (Québec Selection Certificate), which
you will receive after we process your application.
If you have family members living abroad, they must obtain a CSQ before they will receive their permanent resident visa from the federal
government.
INFORMATION CONCERNING THE PROCESSING OF YOUR APPLICATION
WHERE TO MAIL YOUR APPLICATION
• You must mail your application to the Direction de l’immigration familiale et humanitaire or to the Service Immigration-Québec (SIQ) outside
Montréal covering the territory where you live.
• If you need applications for your family members in Québec, we recommend that you pick them up at our offices. This will help you obtain
the selection certificates as quickly as possible.
If you currently live in the administrative region of Estrie, Montérégie, Montréal or Outaouais:
Direction de l’immigration familiale et humanitaire
285, rue Notre-Dame Ouest, 4e étage
Montréal (Québec) H2Y 1T8
If you currently live in another region of Quebec, please consult the website of the Ministry:
http://www.immigration-quebec.gouv.qc.ca/en/reach/adresses-quebec.html
PROCESSING OF YOUR APPLICATION
• Once we receive your application for a selection certificate and those of your family members who are already in Québec and who are also
Convention refugees or protected persons, as well as all the necessary documents, we will mail you your selection certificate and those of
your family members.
• Once Citizenship and Immigration Canada confirms to us that your application for permanent residence is in process, if applicable, we will
send you applications for a selection certificate for the members of your family who are abroad or who are in Québec but who are not
Convention refugees or protected persons.
• Once you return the completed selection certificate applications for the members of your family who are living abroad or who are currently
in Québec but who are not Convention refugees or protected persons, you must provide new proof of a Québec address.
• Once we receive the selection certificate applications, we will mail the selection certificates to you. A selection certificate is not a permanent
resident visa. Before entering Québec, the members of your family who are abroad must have received their visas from the Canadian Visa
Office.
• It is important that you advise us of any change of address. For further information or to advise us of a change of address, please
call the office serving your region.
Ministère de l’Immigration, de la Diversité et de l’Inclusion
Page 1 of 3
A-0520-DA (2014-08)
INSTRUCTIONS FOR COMPLETING THE FORM
IN QUÉBEC
(Convention refugee or
protected person)
Who must complete the
application?
IN QUÉBEC
(family member not
Convention refugee or
protected person)
ABROAD
• Any person aged 18 or over.
• Any person aged 18 or over.
• Any person aged 18 or over.
• Any person aged 18 or under who
submits an application as the
principal applicant.
• Any person aged 18 or under, if
married or a de facto spouse.
• Any person aged 18 or under, if
married or a de facto spouse.
• Copy of the Certificat de
situation statutaire (statutory
situation certificate) that was
given to you as a refugee
protection claimant by the
Ministère de l’Immigration,
de la Diversité et de l’Inclusion.
NOTE
• Any person aged 18 or under, if
married or a de facto spouse.
Documents to enclose with
your application form for
candidates currently in
Québec
• Copy of the decision notice
from Immigration and Refugee
Board (IRB) or the notice from
Citizenship and Immigration
Canada (CIC).
• Original of the Certificat de
situation statutaire (statutory
situation certificate) that was
given to you as a refugee
protection claimant by the
Ministère de l’Immigration,
de la Diversité et de l’Inclusion,
and, if applicable, those of your
family members (we recommend
that you keep a photocopy).
• Proof of Québec residency, a
copy of your lease or a bill from a
public utility (telephone, electricity,
etc.), indicating your name and
address.
• Proof of Québec residency, a
copy of your lease or a bill from a
public utility (telephone, electricity,
etc.), indicating your name and
address.
You must provide new proof of a
Québec address once you return
the selection applications completed
for the members of your family who
are living abroad or who are
currently in Québec and who are not
Convention refugees or protected
persons.
• Copy of your Refugee
Protection Claimant Document
or Acknowledgement of
Refugee Claim or copy of your
work or study permit, your
temporary resident visa or
temporary resident permit (if
applicable).
• Copy of your Refugee
Protection Claimant Document
or Acknowledgement of
Refugee Claim.
Pay special attention to the
following:
Question 3
Question 3
Questions 4 and 5
Don’t forget to indicate your
apartment number, if applicable.
Don’t forget to indicate your
apartment number, if applicable.
Do not complete.
Question 6
Question 6
Do not complete.
Do not complete.
Questions 7 and 8
These questions are optional if you
are a Convention refugee.
Ministère de l’Immigration, de la Diversité et de l’Inclusion
Page 2 of 3
A-0520-DA (2014-08)
INSTRUCTIONS FOR COMPLETING THE FORM (suite)
IN QUÉBEC
(Convention refugee or
protected person)
Pay special attention to the
following:
IN QUÉBEC
(family member not
Convention refugee or
protected person)
ABROAD
Question 11. Using the services of a paid individual
The forms and instructions were designed to enable persons wishing to immigrate to Québec to fill out the forms
without help.
The Ministère de l’Immigration, de la Diversité et de l’Inclusion does not give priority or special treatment to applications
from individuals who retain the services of a paid individual. All applications are treated in the same way.
If you decide to retain the services of a paid individual, be advised that the Ministère, to better protect sponsors against
dubious or illegal practices, deals only with:
– members in good standing of the Barreau du Québec or the Chambre des notaires du Québec;
– persons with a special authorization issued by the above organizations;
– immigration consultants recognized by the Ministère de l’Immigration, de la Diversité et de l’Inclusion and entered
in the Registre québécois des consultants en immigration.
To find out if an immigration consultant is recognized by the Ministère, consult the register at the following address:
www.midi.gouv.qc.ca/consultant.
If you use the services of an immigration consultant to advise, help or represent you in the framework of this
application, you must notify the Ministère and identify this person. Do not forget to give your personal residence
address along with that of the person who advises, assists or represents you.
Power of attorney: If you want someone to represent you in your dealings with the Ministère, you must send an
original power of attorney, signed by you and this person, to the office responsible for handing your application.
DEFINITIONS
Family member:
– a spouse or de facto spouse, who must be at least 16 years old;
– a dependent child and, if applicable, that child’s dependent child.
Spouse:
A married person who is at least 16 years old, and who:
– was not the spouse of any other person on the marriage date;
– was not de facto spouse of any other person while living apart from his/her spouse for at least one year.
De facto spouse:
A person who is at least 16 years old and who:
– has lived as a spouse for at least one year with a person of the opposite or same sex who is at least 16 years old; or
– has had a marital relationship with this person for at least one year but, due to persecution or the law of the land, cannot live
with this person.
Dependent child:
The biological offspring of either parent, who has not been adopted by any person other than his/her parent’s spouse or de facto
spouse; or the adopted child of either parent.
This child must be:
– he/she is under 19 years of age, and is neither married (he/she is single, widowed, or divorced) nor a de facto spouse; or
– he/she is still substantially dependent on the financial support of one or the other parent, and is 19 years of age or over and,
at least since his/her 19th birthday, has been unable to support himself/herself owing to a physical or mental disability.
This definition also extends to the child of a dependent child.
Ministère de l’Immigration, de la Diversité et de l’Inclusion
Page 3 of 3
A-0520-DA (2014-08)
Application for Selection Certificate – Individual in particular crisis situation –
Protected person on-site and family members
I am completing this application as:
a convention refugee
a protected person
a family member abroad
a family member in Québec who is not Convention refugee or protected person
Reserved for Administration
Individual Reference No:
File No:
1. Identification
Family name at birth:
First name:
Other names that you have used or by which you are known, including maiden name:
Sex:
F
Date of birth:
Year
Month Day
Mother tongue:
Other language spoken:
French
Place of birth:
City
M
English
Other language(s) (Specify)
Citizenship / Nationality
Province / State
Last country of residence
Country
2. Present marital status (Notify us immediately if your status changes.)
Single
Married
De facto spouse
Have you been married more than once?
Yes
Divorced
Separated
Widowed
No
3. Present address
Number
Street
Apartment
City
Province / State
Postal code
Country
Mailing address, if different
Telephone no
Home
Effective date for this address
Year
Month Day
Other (Specify)
4. Home address outside Québec
In the past year, have you lived anywhere in Canada besides Québec?
Yes
No
If yes, specify which province and city:
Ministère de l’Immigration, de la Diversité et de l’Inclusion
from
to
from
to
from
to
Page 1 of 4
A-0520-DA (2014-08)
5. To be completed by the principal applicant in Québec.
• Enter the names of your family members in Québec (your spouse, your de facto spouse, your own or your spouse’s or de facto spouse’s dependent
children). (See definitions section.)
Protected
Family name at birth
First name
Sex
Relationship
Date of birth
Country of birth
person
Year
Month Day
Yes
No
• Enter the names of your family members abroad. It is imperative that your declare all the members of your family (See definitions section.) even those for
whom you do not know the exact place of residence, if you wish that they join you in Québec.
Family name at birth
First name
Sex
Relationship
Date of birth
Year
Month Day
Country of birth
• The address of the family members abroad.
Number
Street
City
Province / State
Postal code
Country
6. To be completed by the principal applicant abroad. Enter the names of your family members (your own or your spouse’s or de facto spouse’s dependent
children (See definitions section.)
Family name at birth
First name
Sex
Relationship
Date of birth
Year
Month Day
Country of birth
7. Language skills:
Knowledge of French:
Knowledge of English:
None
None
Average
Average
Very good
Very good
8. Summary of education:
Number of years of schooling completed:
Primary: ___________________
Secondary: ___________________
Highest degree earned: __________________________________________
Postsecondary: ___________________
University: _____________________
Specialization (if applicable): ________________________________________
9. Current or intended employment in Québec:
Ministère de l’Immigration, de la Diversité et de l’Inclusion
Page 2 of 4
A-0520-DA (2014-08)
10. Attach below a passport-sized photograph of yourself and, if you are the principal applicant, of the dependents who are accompanying you.
(Please write each person’s first and last name on the back of the photo.)
11. Paid individual who advises, assists or represents you in the framework of your application
Have you, in the framework of this application, retained a paid individual to advise, assist or represent you? Yes
No
If Yes, is the person:
– a lawyer who is a member of the Barreau du Québec?
– a notary who is a member of the Chambre des notaires du Québec?
– a person holding a special authorization issued by
the Barreau du Québec or the Chambre des notaires du Québec?
– an immigration consultant?
– another paid individual?
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
If the person is an immigration consultant or another paid individual, give:
Family name
First name
Registration number (as it appears in the Quebec’s register of accredited immigration)
To find the consultant’s registration number, consult the register at the following address: www.midi.gouv.qc.ca/consultant
PROTECTION OF PERSONAL INFORMATION
The personal information appearing on this form, and in any documents that must be appended to it, is required for processing your application
for a selection certificate and the application of the Act respecting immigration to Québec, the Regulation respecting the selection of foreign
nationals, the Regulation respecting the immigration consultants and their administrative regulations.
This information may also be used by the Minister for the purposes of studies, statistics, program evaluation or to convey to you any information
that might affect your application.
Your personal information is confidential and may not be disclosed without your consent unless authorized by law. In particular, the law allows
personal information to be communicated without your consent under certain conditions if such communication is necessary to:
– the application of an Act in Québec;
– the exercise of the rights and powers of an agency of the government of Québec or Canada, including federal immigration authorities;
– the purposes of a service to be provided to you by the Ministère or for performing a contract for services entrusted by the Ministère;
– prosecute an offence against an Act applicable in Québec, or because of the urgency of a situation.
Within the Ministère, access to this information is restricted to personnel who is qualified to receive personal information where such information
is necessary for the discharge of his duties.
With the exception of optional sections, any refusal to answer a question or any omission may result in the rejection of your application or may
delay its processing.
You may be informed about the information concerning you in the Ministère’s possession and, if applicable, request in writing that this
information be corrected. For more information, contact the office that is processing your application. If this office is unable to provide you with
the information requested, contact the departmental officer responsible for the protection of personal information at the Secrétariat général,
Ministère de l’Immigration, de la Diversité et de l’Inclusion at the following address: Édifice Gérald-Godin, 360, rue McGill, 4e étage, Montréal
(Québec) H2Y 2E9.
Ministère de l’Immigration, de la Diversité et de l’Inclusion
Page 3 of 4
A-0520-DA (2014-08)
DECLARATION
I hereby agree to comply with all of the conditions attached to issuance of my « Certificat de sélection du Québec » (CSQ) (Québec Selection
Certificate).
I further declare that all the information contained in this application is true.
I acknowledge and accept that the Ministère de l’Immigration, de la Diversité et de l’Inclusion may:
– Verify or have other parties verify the accuracy of the information that I have provided and if I provide the Department, investigator or auditor
with information that I know or should have known to be false or misleading with respect to my application for a Québec Selection Certificate,
I am breaking the law and subject to a fine;
– Refuse to consider an application for a Certificate from someone who, within the past five years, has submitted false or misleading
information or documentation with an application undr the Act respecting immigration to Québec;
– Revoke a Québec Selection Certificate when the application contains a false or misleading information or documentation, when the
Certificate was issued by error or when the conditions governing its issuance no longer exist.
Year
Month Day
I have signed, in __________________________________________________________________________________
City
Country
Signature : ___________________________________________________________________________________________________________________
Ministère de l’Immigration, de la Diversité et de l’Inclusion
Page 4 of 4
A-0520-DA (2014-08)