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Appendix 3 - Declaration of Citizenship or Permanent Resident

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.

I hereby certify and confirm that:

  1. I am (please check one)

    1. A Canadian citizen

      1. by birth ( )

      2. by naturalization ( )

        Date of naturalization:

        _________________
        (YYYY/MM/DD)

      OR

    2. A permanent resident of Canada within the meaning of the Immigration Act ( )

      Date of naturalization:

      _________________
      (YYYY/MM/DD)

2. I performed the services of ________________________________

From_________________________
(YYYY-MM-DD)

To____________________________
(YYYY-MM-DD)

for the production entitled: ______________________________________

3. My present address is:

_________________________
(apt./number/street)

____________________________
(city/town)

_________________________
(province)

____________________________
(postal code)

4. Upon request, I agree to provide the Canadian Radio-television and Telecommunications Commission (CRTC) with documentary evidence confirming my status as citizen or permanent resident of Canada.

Name of Applicant

Surname (print) _________________________

Given name (print) ____________________________

(signature of applicant) _________________________

(date)____________________________



CRTC - Appendix 3 (2017-02-06) - Canadian Program Certification - Declaration of Citizenship or Permanent Resident

***End of Document***

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