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:



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

      Date of naturalization:


2. I performed the services of ________________________________



for the production entitled: ______________________________________

3. My present address is:




(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) _________________________


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

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