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?
Yes _______________________________ ( nationality)
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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