SCHEDULE 19 A - Canada

1 (DISPONIBLE EN FRAN AIS - IMM 5982 F)PROTECTED WHEN COMPLETED - BPage 1 of 1 IMM 5982 (07-2021) ESCHEDULE 19 A HOME CHILD CARE PROVIDER AND HOME SUPPORT WORKER (LANGUAGE AND education )The principal applicant must complete this there is not enough space to provide all the necessary information, attach to this form a separate sheet of paper with further details. Print your name at the top for each additional sheet and indicate the form s title and the number of the question you are 1: INDICATE WHICH PILOT YOU ARE APPLYING FORHome child care provider (NOC 4411)Home support worker (NOC 4412) SECTION 2: FULL NAMEF amily NameGiven Name(s)SECTION 3: UCI / ID CLIENT NUMBER (if you have one)DATE OF BIRTHYearMonthDaySECTION 4: SECTION 5: LANGUAGE PROFICIENCYa) Which will be your first official language in Canada ?

2 EnglishFrenchNoYesProvide original language test results for speaking, listening, reading and 6: CANADIAN EDUCATIONAL CREDENTIAL OR EDUCATIONAL CREDENTIAL ASSESSEMENT (ECA) REPORTDo you have a Canadian one-year post-secondary educational credential (or higher)?NoYesProvide a copy of your completed Canadian post-secondary educational you obtained an ECA report from an organization designated by IRCC indicating that your completed foreign educational credential is equivalent to a completed Canadian one-year post-secondary education credential (or higher)?NoYesProvide an original ECA report from the designated organization and proof of your completed foreign educational 7: CANADIAN WORK EXPERIENCEa) Do you have at least 24 months of qualifying Canadian work experience in an eligible occupation obtained within the last 36 months?

3 NoYesProvide proof of work experience on SCHEDULE 19B and include it with your (YYYY-MM-DD)Personal information provided on this form is collected by Immigration, Refugees, and Citizenship Canada (IRCC) under the authority of the Immigration and Refugee Protection Act (IRPA). The personal information provided may be used for the purpose of processing an application. The personal information provided may be disclosed to other federal government institutions, law enforcement bodies, provincial/territorial governments and foreign governments for the purpose of validating identity, eligibility and admissibility. Personal information may also be used for purposes including research, statistics, program and policy evaluation, internal audit, compliance, risk management, subsequent program eligibility, strategy development and reporting.

4 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. 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 042.