Appendix 5 - Community

Sample form only: do not complete

This form is for reference purposes only. It is not to be completed in this format.

To complete this and submit it to the CRTC, download the form.

You must complete the tables below and save your document as:

Doc5 - Appendix 5 – Ownership Information


All columns must contain the complete information requested.

  1. As indicated in the Procedures for filing confidential information and requesting its disclosure in Commission proceedings, Broadcasting and Telecom Information Bulletin 2010-961, you may designate as confidential the civic number, street name and postal code of a residential address.
  2. If you wish to designate this information as CONFIDENTIAL:
    1. Name your confidential document as: NOT WEB – APP – Doc5 – CONFDOC - Appendix 2A – Ownership Information
    2. Name your abridged document, in which the information in the columns entitled “Civic Number and Street Name” and “Postal Code” is removed, as: APP – Doc5 – ABRIDGED VERSION – Appendix 2A – Ownership Information

Ownership Information

Name of the Licensee:



Directors and Officers

Supply a list of the current directors and officers (Footnote 3) (Footnote 4)

Name of the Directors(Footnote 1) (Footnote 3) / Officers(Footnote 4) Residential Address * Canadian Citizen(Footnote 2) (y/n) Directors' Date of Appoint-ment(Footnote 3) Officer
Position(Footnote 4)
Civic Number and Street name City/Province Postal Code
Chief Executive Officer
(or the person in a position with similar functions)
Provide the name, complete residential address, citizenship and title of the position of this person

Residential address refers to a person's ordinary residence: the place in which the person's lifestyle is centered and to which the person regularly returns.  Note that a Post Office Box number is not accepted.


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