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SCHEDULE II

(section 3)

TRANSFER OF OFFENDERS ACT


Request for Transfer to Canada under terms of
the treaty between Canada and _______________
                                                               (foreign state)
On the Execution of Penal Sentences.
NAME: ____________________ INSTITUTION: _______________________
 
1. APPLICATION
I hereby request a transfer to Canada to complete my sentence, for the following reasons:
Signature ________________________
Witness __________________________
Date ____________________________
2. PERSONAL IDENTIFICATION
(a) aliases_______________________________
(b) birth date_____________________________
day      month      year   
(c) place of birth__________________________
city/province/statecountry   
(d) last address in Canada_________________
number street apt   
_________________
city      province   
3. NEXT OF KIN
Mr.                                                                            
(a) Mrs._________________________________
Miss                last name            given names   
Ms                                                   and initials     
(b) address_____________________________
number      street      apt      city   
_____________________________
province/country               state   
(c) telephone no.________________________
(d) relationship to you. My________________
4. CITIZENSHIP
Are you a Canadian citizen by                           
(a) birth                                             ___________
yes      no   
(b) the grant of a certificate of    ___________
citizenship                                     yes      no   
(c) the grant of a certificate of                             
naturalization                            ___________
yes      no   
NOTE:  You are required to prove that you are
a Canadian citizen. For assistance in  
this matter, contact the nearest             
Canadian diplomatic post.                     
5. EDUCATION AND WORK EXPERIENCE
Briefly state your education and work           
experience as indicated below:                       
(a) Level of education__________________
(b) Current training programs or                     
occupation________________________
(c) Previous work experience or                     
occupational training________________
6. CHOICE OF DESTINATION
(a) The following is to be completed by an  
applicant who is                                            
(i) less than sixteen years of age,             
(ii) serving a term of imprisonment of      
less than two years,                                
(iii) on parole, or                                             
(iv) on probation.                                           

Number in order of preference, the         
provinces or territories of Canada to      
which you would be interested in            
transferring:                                                   
__________Newfoundland                     
__________Nova Scotia                           
__________Prince Edward Island         
__________New Brunswick                    
__________Québec                                    
__________Ontario                                    
__________Manitoba                                 
__________Saskatchewan                      
__________Alberta                                    
__________British Columbia                  
__________Northwest Territories         
__________Yukon Territory                    

(b) The following is to be completed by an  
applicant who has been sentenced to    
two years or more in a penal institution:
Number, in order of preference, the         
regions to which you would be                 
interested in transferring:                           
__________Atlantic                                   
__________Quebec                                  
__________Ontario                                   
__________Prairies                                   
__________British Columbia                  

NOTE: This application will be used to           
determine whether you will or will not
be transferred to Canada. If you are   
transferred, your choice of province  
or region will be considered but your
actual destination will be decided by 
Canadian correctional officials after   
your arrival.                                              
7. SUPPORT
List persons or agencies who might be   
willing to give you support following        
your transfer.                                                   
name                        address            
__________________________________
__________________________________
8. OTHER INFORMATION
Set out any other information that you     
think Canadian officials should know      
about you or your case.                              
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