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A-0591-A0
Payment by credit card Confidential (2018-09)

Official use only

Individual reference number 

File number

Important – You must sign this form and enclose it with your application if you are paying the required fees by credit card.

Reason for the application

Application from an employer Application for permanent selection for:
concerning a job offer:
Skilled worker Self-employed worker
Temporary Permanent (Québec experience
program only)

Application for temporary selection for: Entrepreneur Live-in caregiver

Studies Temporary work
Recognition as an immigration consultant:
Medical treatment
Application
 Renewal
for recognition
A
 pplication for an undertaking –
Family reunification
C
 omparative evaluation for studies done
outside Québec

  The contact information for

the principal applicant must be
Principal applicant (person making the application)
provided if he or she is not
the credit card holder.  
Family name First name

   
Date of birth (year) (month) (day)

  Provide the family name

and first name of the credit
Authorization
card holder. You must send us
the original form signed by I authorize the Ministère de l’Immigration, de la Diversité et de l’Inclusion to charge the amount of CAN$
the cardholder. A photocopy to my credit card.
will not be accepted.
 
Family name First name

   
Signature Date (year) (month) (day)

Credit card
Visa  MasterCard Number:       

Expiry:   Security code CVV

(Month) (Year)

American Express Number:       

Expiry:   Security code CVV

(Month) (Year)

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Ministère de l’Immigration, de la Diversité et de l’Inclusion Print Erase A-0591-A0 (2018-09)