Contact Information Sheet for Canadians Imprisoned Abroad

Information obtained through this form is confidential and is used in accordance with the provisions of Canada’s Privacy Act.

Your personal identification

Full name:

___________________________________________

Date and place of birth:

_______________________________(dd/mm/yyyy)

_______________________________ (location)

Passport information:

_______________________________(number)

_______________________________ (dd/mm/yyyy)

Do you have another nationality other than Canadian?


Checkbox Yes _______________________________ ( nationality)

Checkbox No

Prisoner number:

_______________________________

Your consular representative in the country

Full name:

___________________________________________(full name of consular representative)

Title:

___________________________________________(title of consular representative)

Telephone and fax numbers:

_______________________(telephone)

_______________________ (fax)

E-mail:

_______________________________

Your legal representative

Full name:

___________________________________________(full name of lawyer/legal representative)

Address:

_______________________  (street address, city)

_______________________ (province/state, country)

Telephone and fax numbers:

_______________________(telephone)

_______________________ (fax)

E-mail:

_______________________________

Prison contact information

Name:

___________________________________________

Address:

_______________________  (street address, city)

_______________________ (province/state, country)

Telephone and fax numbers:

_______________________(telephone)

_______________________ (fax)

E-mail:

_______________________________

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