PROTECTED B (WHEN COMPLETED)
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ANNEX to a passport application received at Official Travel
WARNING to all applicants—Any false or misleading statement on this form or relating to any document in support of this application, including concealment of any material
fact, may lead to refusal to issue or revocation of a passport and be grounds for criminal prosecution.
Failure to complete all the required sections of this form will result in your application being refused.
PRINT OR TYPE IN CAPITAL LETTERS using black or dark blue ink.
1
Personal Information as indicated on the passport application submitted to Official Travel
Surname (last name)
Given name(s)
Date of birth
Year
Month
Day
Sex
2
Female
Male
Daytime telephone number
Evening telephone number
Declaration of Applicant (check appropriate box)
Indicate which service is being requested (select one box)
Official Passport only 1
Regular Passport only 2
Official and Regular Passport 3
I understand that my official passport is to be used only when on official business for the
Government of Canada.
I understand that my regular passport is to be used when not on official business for the
Government of Canada.
I am requesting a regular passport be issued to me based on the information provided on my
application for an official passport.
I understand that the standard passport fee applies to my application for a regular passport and
hereby authorize Passport Canada to process the payment submitted with this application.
I understand that my official passport is to be used only when on official business for the
Government of Canada.
I understand that my regular passport is to be used when not on official business for the
Government of Canada.
I am requesting a regular passport be issued to me based on the information provided on my
application for an official passport.
I understand that the standard passport fee applies to my application for a regular passport and
hereby authorize Passport Canada to process the payment submitted with this application.
DECLARATION—I solemnly declare that I am a Canadian citizen and that all of the statements made in this annex to my application
are true. I declare that I have read and understood the WARNING to all applicants at the top of this page as well as the declaration
associated with the service requested.
Signature of applicant
Date
Signed at
Year
Month
Day
City
1 Include
Province/Territory/State
form PPTC 467, Passport Information Billing Form (if applicable).
2 See
instructions for payment on application form (PPTC 054, Adult Simplified Renewal Passport Application or PPTC 153, Adult
General Passport Application).
3 Include
form PPTC 467, Passport Information Billing Form (if applicable) and see instructions for payment on application form (PPTC
054, Adult Simplified Renewal Passport Application or PPTC 153, Adult General Passport Application).
Aussi disponible en français
PPTC 507-ENG (2011-11) R5