EFTA00811662.pdf

Citizenship and Citoyennet6 et PROTECTED VYNEN COMPLETED - B 1+1 Immigration Canada Immigration Canada PAGE 1 OF 4 Language of correspondence APPLICATION FOR CRIMINAL REHABILITATION ID English OR El French SECTION A TO BE COMPLETED BY APPLICANT 1 MI APPLICATION FOR APPROVAL OF REHABILITATION 2 r FOR INFORMATION ONLY SECTION B TO BE COMPLETED BY APPLICANT Family name Given name(s) - Do not use initials 1 Epstein Jeffrey Edwards Dale of birth (YYYY-MM-DD) Country of birth Citizenship 2 1953-01-20 3 Sea Or Male O Female 4 USA 5 USA 6 Mental status r Single El Married LI Common-law O Vtadowed O Divorced O Separated 7 All other names that I use or have used (Include maiden name, previous married name(s), aliases and nidummes, legal change of name) — 1) Family name i Given name(s) I 2) Family name Given name(s) Il l My home address is No & street I Apt/Unit Little St. James Island City/Toren Province I State / Country Postal / ZIP code St. Thomas U.S. Virgin Islands, USA 00802 LI Making address All correspondence should be mailed to box 8 El or to: No 8 street IP4A/Unit 6100 Red Hook Quarter B3 City/Town Province! State / Country Postal / ZIP code St. Thomas U S. Virgin Islands, USA 00802 Home telephone no. Business telephone no. Fax no. Time E ASA 10 11 12 13 Indicate most convenient time 11 to reach you by telephone 3 r PM E-mail address (Indicating an e-mail address will authorize all correspondence, including fie and personal information, to be sent to the e-mat address you 14 16 I may be inadMiSaile to Canada because of the following offense*); (use a separate sheet if necessary, entitled #15: Offences / Convictions) DATE(S) OF OFFENCE(S)! STATUTE OFFENCE(S)/CONVICTION CONVICTION PLACE OF OFFENCE(S)/CONVICTION SENTENCES) NUMBER(S) (YYTY-MM-DO) Solicitation of Prostitution 2008-06-30 Palm Beach County, Florida 12 Nos. FS 796.07 Procuring a person under 18 for Prostitution 2008 - 06- 30 Palm Beach County, Florida 6 Mos. and FS 796.03 12 Nos of Probation On a separate sheet of paper, explain in detail the events/circumstances leading to the offence(s)/conviction(s). Indicate 118: Events! Circumstances on 16 the sheet of paper. WARNING DETAILS OF ALL OFFENCES AND CONVICTIONS MUST BE ACCURATELY RECORDED ON THIS DOCUMENT. PROVIDING FALSE OR MISLEADING INFORMATION WILL LIKELY RESULT IN A REFUSAL OF YOUR APPLICATION AND MAY PERMANENTLY BAR YOUR ADMISSION TO CANADA. imM 1444 (08-2012) E This form Is made available by CitlzonsMp and Immigration Canada and is not to be sold to applicants. (DISPONIBLE EN FRANCAIS • IMM 1444 F) Canadig EFTA00811662  PAGE 2 OF 4 emlain the purpose of your visit or stay in Canada To attend the TED 2018 Conference, entitled The Age of Amazement, in Vancouver , BC from April 17 10-14,2018, and before, during and after the conference, to meet with, and share information and ideas with other professionals regarding the topics addressed at the TED Conference. On a separate sheet of paper, provide reasons why you consider yourself to be rehabilitated and why you do not represent 18 a risk to pubac safety. Indicate #18: Rehabilitation Factor on the sheet of paper. 19 Addresses since the age of 18. (Use a separate sheet if necessary) cs Forms will be returned if the e is any period of time for which you have not shown an address. Do not use post office (■) box addresses. DATES NUMBER AND STREET APT. PROVINCE I STATE (tYYYMM) (YYYY-IMA) (Do not useii boxes) NO. COUNTRY Little St. James Island St. Thanes USVI, USA 358 El Brillow Way Palm Beach FL, USA 9 East 71st Street New York NY, USA 34 East 69th Street New York NY, USA 22 Avenue Foch Paris FR 49 Zorro Ranch Road (Other Addresses) Stanley NM, USA Provide the details of your employment history since the age of 18. Start with the most recent information. Under "OCCUPATIO N", wile your occupation or job title if you were working. If you were not working, provide information on what you were doing (for example: unemployed. studying, traveling, in 20 detention, etc.) _ Note: Please ensure that you do not leave any gaps in time. 0 Failure to account for all time periods will result in a delay in the processing of your appktahon. DATES FROM TO NAME AND ADDRESS OF COMPANY (rtYY-1.41A) (Write name in lull do not use abbreviations) OCCUPATION (TYrv-mkt) Southern Trust Company, Inc. Florida Science Foundation FinancisiTrust Conway Inc, J Epstein & Company. Inc. Bear Steams & Company The Dalton School (Out Employment) THE INFORMATION YOU PROVIDE IN THIS DOCUMENT IS COLLECTED UNDER THE AUTHORITY OF THE CANADA IMMIGRATION AND REFUGEE PROCTECTION ACT AND IS STORED IN PERONAL INFORMATION BANK NUMBER CIC PPU 042, 054 OR 300. THE INFORMATION IS PROTECTED UNDER THE PROVISIONS OF THE PRIVACY ACT AND IS ACCESSIBLE TO YOU UPON REQUEST. 1 I certify that the Information provided by me is true and complete to the best of my knowledge. I also certify that I am not currently charged with any criminal offence. SIGNATURE OF APPLICANT Date (YYYY-MM-DD) IMM 1444 (08-2oi2)E EFTA00811663  PAGE 3 OF 4 SECTION C TO BE COMPLETED BY THE OFFICER. 1 Name of originating office 2 File no. 3 NW) file no. (if known) 4 Cost recovery oode Fee GST Receipt no. 5 FOSS / NCMS ID no. 6 Equivalent offence(s) under Canadian law 7 Maximum penalty under Canadian law A36(1)a) O A36(1)b) A36(1)c) 8 Inadmissibility provision(s) 19' IM A36(2)a) O A36(2)b) O A36(2)c) Date when subject 19' (YYYY-MM-DD) 9 Eligiole to apply for rehabilitation? Ille. O Yes O No 10 was / will be eligible 11 If subject is not eligible. state reason(s) 12 Officers recommendation I recommend approval of rehabilitation O I recommend an application for a Temporary Resident's Permit El I do not recommend approval of rehabilitation O I do not recommend an application for a Temporary Residents Permit 13 Reasons for recommendation 14 Name of officer 16 Signature of officer Date FiYYY-MMDD) 1MM 1444 (08-2012) E EFTA00811664  Reviewing officer's recommendation Ile• l illi Ill I concur / approve r II I do not concur / approve PAGE 4 OF 4 18 Comments 19 Name of reviewing officer 20 Signature of reviewing officer Date (YYYY-MM-DD) 1_1 1 List of documents or photocopies attached - check those attached ▪ Passport D Drivers License and USA Birth of Certificate (USA-born citizens only) O Court Judgement(s) D Text of non-Canadian statutes ▪ Police certificate O Documentation re: sentence, parole, probation, fine or pardon O Documentation re: juvenile offender D Other documentation (specify) I certify that a copy of these documents has been provided to the applicant and that the applicant has been given an opportunity to provide comments. 22 Name of officer 23 Signature of officer Date (YYYY-MM-DD) SECTION D FOR OFFICE USE ONLY Notification by diode-mail) received that authority from the Minister for Initials Date (YYYY-MM-DD) reef under A313(1)(b) or A36(1)(c) was: ile• O Granted D Refused Authority from the Ministers delegate for relief under A36(2Xb) or Date (YYYY-MM-DD) A36(2)(c) granted Pio O Yes O No Name (please print) Title SIGNATURE Date (YYYY-MM-DO) NAM 1444 (08-2012) E EFTA00811665