l♦I Government

of Canada
Gouvernement
du Canada
PROTECTED WHEN COMPLETED- B
PAGE OF

APPLICATION FOR (WORKPERMIT) VISA

If you need more space for any section, print out an additional page containing the appropriate section, complete and submit it with your application.

1 UCI 3 * Visa requested

Validated
QA064382 W-01 W-01

PERSONAL DETAILS
� Full name
*Family name (as shown on your passport or travel document) Given name(s) (as shown on your passport or travel document)

WASIM MOHAMMAD

� Have you ever used any other name (e.g. Nickname, maiden name, alias, etc.)? □ •No □ •Yes
Family name Given name(s)

�*Sex

MALE
�* Date of birth
1969
yyyy
11
MM
15
DD
� Place of birth
*City/Town
GAFARGAON,2223-MYMENSINGH, BANGLADESH
•I Country or Territory
QATAR

� *Citizenship
BANGLADESHI

7 I Current country or territory of residence:

Country or Territory Status Other From To
* *
QATAR ACTIVE NO
2016-06-09 2024-11-17

□ □
YYYY-MM-DD YYYY-MM-DD
l,!_J Previous countries or territory of residence: During the past five years have you lived in any country or territory other than your country of *No •Yes
citizenship or your current country or territory of residence (indicated above) for more than six months?
Country or Territory Status Other From To

YYYY-MM-DD YYYY-MM-DD

□
YYYY-MM-DD YYYY-MM-DD
L!J Country or Territory where applying: Same as current country or territory of residence? *No D *Yes
Country or Territory Status Other From To

CANADA IN THE PROCESS

2024-11-15 2027-11-17
YYYY-MM-DD YYYY-MM-DD
� * a) Your current marital status Date
b) (If you are married or in a common-law relationship) Provide the date
MARRIED
on which you were married or entered into the common-law relationship
YYYY-MM-DD
c) Provide the name of your current Spouse/Common-law partner
Family name Given name(s)

FOR OFFICE USE ONLY - DO NOT WRITE IN THIS SPACE

Canada
This form is made available by Immigration, Refugees and Citizenship Canada and is not to be sold to applicants.
IMM 5257 (04-2024) E (DISPONIBLE EN FRAN�AIS - IMM 5257 F)
APPLICATION FOR VISA)
 PAGE OF
ApplicantName Date of Birth
!
MOHAMMED ABDUR RASHID 1987 01 01

PERSONAL DETAILS (CONTINUED)

2!J a) Have you previously been married or in a common-law relationship? D*No D *Yes
bl Provide the following details for your previous Spouse/Common-law Partner:
Family name Given name(s)
WASIM
MOHAMMAD

cl Date of birth di Type of relationship From To

1969 11 15
yyyy MM DD YYYY-MM-DD YYYY-MM-DD
LANGUAGE(SJ
� *a)Native language/Mother Tongue *bl Are you able to communicate in English and/or French? cl In which language are you most at ease?
BANGLA English

d) Have you taken a test from a designated testing agency to assess your proficiency in English or French? I l *No rl *Yes
PASSPORT
� * Passport number � *Country or territory of issue � * Issue date � * Expiry date
EJ0156781 Canada

� * For this trip, will you use a passport issued by the Ministry of Foreign Affairs in Taiwan that includes your personal identification number? □
YYYY-MM-DD
*No D *Yes
YYYY-MM-DD

� * For this trip, will you use aNational Israeli passport? □ *No D *Yes

□
NATIONAL IDENTITY DOCUMENT
� Do you have a national identity document? *No D*Yes

� Document number � Country or territory of issue � lssue date � Expiry date

8253924032 Canada
YYYY-MM-DD YYYY-MM-DD
US PR CARD
� Are you a lawful Permanent Resident of the United States with a valid alien registration card (green card)? D*No D*Yes

� Document number � Expiry date

245384257621 2030 09 03
YYYY-MM-DD
CONTACT INFORMATION
If submitting your application by mail:
- All correspondence will go to this address unless you indicate your e-mail address below.
- Indicating an e-mail address will authorize all correspondence, including file and personal information, to be sent to the e-mail address you specify.
- If you wish to authorize the release of information from your application to a representative, indicate their e-mail and mailing address(es) in this section and on the IMM5476 form.

1 I Current mailing address

P.O.box Apt/Unit Street no. * Street name
P1 2223 GAFARGAON,2223-MYMENSINGH, BANGLADESH

*City/Town *Country or Territory Province/State Postal code District

GAFARGAON QATAR Mymensingh 2223 Mymensingh

2 I Residential address Same as mailing address? D*No D *Yes

Apt/Unit Street no. Street name City/Town

Country or Territory Province/State Postal code District

� Telephone no. DCanada/US □ Other � Alternate Telephone no. DCanada/US D Other

Type Country Code No. Ext. Type Country Code No. Ext.
+1(438) ************
I I I I I I
� Faxno. � E-mail address
DCanada/US Country Code No. Ext.
D Other
I I I

IMM 5257 (04-2024) E IMMIGRATION, REFUGEES AND CITIZENSHIP CANADA

APPLICATION FOR VISA IMMIGRATION, R£FUG1£S ET CITOYENNET£ CANADA
 PAGE OF
Applicant Name Date of Birth
! MOHAMMAD WASIM
1969 11 15

DETAILS OF CANADA
..!.J *a) Purpose of my w o r k b) Other

CANADA TORONTO

*From *To � *Funds available for my stay (CAD)

�
Indicate how long
you plan to stay ► 2024 11 15 2027 11 14 CAD$ 175

I
YYYY-MM-DD YYYY-MM-DD
4 Name, address and relationship of any person(s) or institution(s) I will visit:
*Name

SALAUDDIN KHAN

1 Relationship to me * Address in Canada

BROTHER MGFM+RR Toronto, Ontario, Canada

Name

2 Relationship to me Address in Canada

□
EDUCATION
Have you had any post secondary education (including university, college or apprenticeship training)? *No D *Yes
If you answered "yes", give full details of your highest level of post secondary education.

From Field of study School/Facility name

yyyy MM
1 To City/Town Country or Territory Province/State

yyyy MM

EMPLOYMENT
Give details of your employment for the past 10 years, including if you have held any government positions (such as civil servant, judge, police officer, mayor, Member of Parliament, hospital
administrator, employee of a security organization). Do not leave gaps. If retired, not working or studying, please indicate. If you are retired, please provide the 10 years before your
retirement.
From • Current Activity/Occupation • Company/Employer/Facility name

•vvvv
To
..... *City/Town • Country or Territory Province/State

yyyy MM
From Previous Activity/Occupation Company/Employer/Facility name

2
vvvv
To
.... City/Town Country or Territory Province/State

yyyy MM
From Previous Activity/Occupation Company/Employer/Facility name

=
To
.... City/Town Country or Territory Province/State

yyyy MM

IMM 5257 (04-2024) E IMMIGRATION, REFUGEES AND CITIZENSHIP CANADA

APPLICATION FOR VISA IMMIGRATION, R£FUG1£S ET CITOYENNET£ CANADA
 PAGE OF
Applicant Name Date of Birth
! MOHAMMAD WASIM
1969 11 15

BACKGROUND INFORMATION
You must complete this section if you are 18 years of age or older.

a) Within the past two years, have you or a family member ever had tuberculosis of the lungs or been in close contact with a person with tuberculosis? D Yes
bl Do you have any physical or mental disorder that would require social and/or health services, other than medication, during a stay in Canada? D Yes
cl If you answered ''yes" to question 1 a) or 1 bl, please provide details and the name of the family member (if applicable).

2.J a) Have you ever remained beyond the validity of your status, attended school without authorization or worked without authorization in Canada? □ No □ Yes
bl Have you ever been refused a visa or permit, denied entry or ordered to leave Canada or any other country or territory? □ No □ Yes
cl Have you previously applied to enter or remain in Canada? □ No □ Yes
d) If you answered •yes• to question 2a), 2b), or 2C please provide details.

..!.J a) Have you ever committed, been arrested for, been charged with or convicted of any criminal offence in any country or territory? □ No D Yes
bl If you answered •yes• to question 3a) above, please provide details.

� a) Did you serve in any military, militia, or civil defence unit or serve in a security organization or police force (including non
obligatory national service, reserve or volunteer units)? □ No D Yes
bl If you answered yes to question 4a), please provide dates of service and countries or territories where you served.

� Are you, or have you ever been a member or associated with any political party, or other group or organization which has engaged in or advocated violence
as a means to achieving a political or religious objective, or which has been associated with criminal activity at any time? □ No □ Yes
� Have you ever witnessed or participated in the ill treatment of prisoners or civilians, looting or desecration of religious buildings? □ No □ Yes
If you answered ayes" to any of questions 3 to 6 above, or upon request of a visa officer, you MAY BE REQUIRED to fill out IMM 5257 Schedule 1.

IMM 5257 (04-2024) E IMMIGRATION, REFUGEES AND CITIZENSHIP CANADA

APPLICATION FOR VISA IMMIGRATION, R£FUG1£S ET CITOYENNET£ CANADA
I
PAGE OF
Applicant Name Date of Birth
MOHAMMAD WASIM 1969 11 15

SIGNATURE
Citizenship and Immigration Canada {CIC), or an organization at CIC' request, may want to contact you in the future to ask you about any services you received from CIC prior to the
application process {such as participation in an information forum), during the application process {including the application process itself as well as orientation or accreditation services), and
services received after arriving in Canada {including settlement, integration and citizenship). CIC will use this information, along with the information provided by other individuals, for
research, performance measurement or evaluation purposes. CIC will not use this information to make any decisions about you personally.

Do you consent to be contacted by CIC, or an organization at CIC's request, in the future? {Y/N) D Yes

I consent to the release to Citizenship and Immigration Canada {CIC) and Canada Border Services Agency {CBSA) of all records and information for the purpose of processing my request that
any government authority, including police, judicial and state authorities in all countries in which I have lived may possess about me. This information will be used to evaluate my suitability
for admission to Canada or to remain in Canada pursuant to Canadian legislation.

I declare that I have answered all questions in this application fully and truthfully.

Si nature of A licant or Parent/Le al Guardian's for a erson under 18 ears of a e. Date: YYYY-MM-DD
MOHAMMAD WASIM 2024-11-17

IMPORTANT NOTE:
This application must be signed and dated before it is submitted by mail.
Do not forget to include photos, fees {if applicable) and any other documents required. Review the application guide for more information and verify that you have
completed and provided all of the required documents as per the document checklist.

PRIVACY NOTICE
Personal information provided on this form is collected and will be used, disclosed, and retained by Immigration, Refugees and Citizenship Canada {IRCC) under the authority of the Immigration
and Refugee Protection Act {IRPA). The personal information provided will be used for the purpose of processing applications. The personal information provided may be disclosed to other
federal government institutions and third parties including law enforcement bodies, provincial/territorial governments and/or foreign governments for the purpose of validating identity,
eligibility and admissibility.

The personal information collected on an application, and other information collected in support of an application, may be used for computer analytics to support processing of applications and
decision making, including your application. Personal information, including from computer analytics, may also be used for purposes including research, statistics, program and policy
evaluation, internal audit, compliance, risk management, strategy development and reporting.

Where biometrics are provided in support of an application, the fingerprints collected will be stored and shared with the RCMP. The fingerprint record may also be disclosed to law enforcement
agencies in Canada in accordance with subsection 13.11 (1) of the Immigration and Refugee Protection Regulations. The information may be used to establish or verify the identity of a person in
order to prevent, investigate, or prosecute an offence under any law of Canada or a Province. This information may also be used to establish or verify the identity of an individual whose identity
cannot reasonably be otherwise established or verified because of physical or mental condition. Canada may also share immigration information related to biometric records with foreign
governments with whom Canada has an agreement or arrangement.

Failure to complete the form in full may result in a delay or the application not being processed. The Privacy Act gives individuals the right of access to, protection, and correction of their
personal information. Further details are available in Info Source. If you are not satisfied with the manner in which IRCC handles your personal information, you may exercise your right to file a
complaint to the Office of the Privacy Commissioner of Canada. The collection, use, disclosure and retention of your personal information is further described in IRCC's personal information bank
- IRCC PPU 068.

IMM 5257 (04-2022) E IMMIGRATION, REFUGEES AND CITIZENSHIP CANADA

APPLICATION FOR VISITOR VISA (TEMPORARY RESIDENT VISA) IMMIGRATION, R£FUG1£S ET CITOYENNET£ CANADA