I. Name, Address, Email & Phone
Your Name (Last, First, Middle)*
Address*
Email*
Telephone*
II. How many DUI’s have you had? Please provide details for each one.
# of DUI(s)
Details for each DUI
III. How long ago was your last DUI conviction?
Date of Last DUI Conviction (Mo/Day/Yr)
IV. Have you served any jail time for DUI?
Jail Time
YESNO
V. When did you complete your last DUI sentence?
Date of Last DUI Sentence Completed (Mo/Day/Yr)
VI. Were you acquitted of a DUI charge but still fingerprinted? Please provide details.
Acquitted but Fingerprinted
Details
VII. Were you arrested for DUI but not charged? Please provide details.
Arrested but Not Charged
VIII. If you have convicted of DUI, have you committed any other acts that would prevent you from entering Canada? If yes, please provide details.
Committed Other Acts Preventing Canada DUI Entry
IX. Have you ever been convicted of any of the following? If yes, please provide details.
Convictions
TheftDangerous DrivingAssaultPossessing or Trafficking drugs or controlled substancesManslaughter
Were you under the age of 18 at the time?
X. Have you ever been convicted of any crime and had it pardoned afterwords? Please provide details. If Yes, were you convicted as an adult despite being younger than 18 in a country with provisions for young offenders?
Convicted and Pardoned
YesNo
Convicted as an Adult
XI. Have you ever been refused entry to Canada or deported? If yes, please provide details.
Refused or Deported
Additional Message
By checking the box below I certify that the information provided on this questionnaire is true and correct to the best of my knowledge.
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IMPORTANT: Review all sections carefully before submitting.
