Canadian Program Certification

Appendix 3 - Declaration of Citizenship or Permanent
Resident
 
I hereby certify and confirm that:
 
1) I am (please check one)
 
  a) A Canadian citizen
 
    i) by birth (  )
 
    ii) by naturalization (  )
 
      Date of naturalization: ________________
                                  (YYYY/MM/DD)
 
OR
 
  b) A permanent resident of Canada within the meaning of the Immigration Act (  )
 
    Date of admission as a permanent resident: _________________
                                                                (YYYY/MM/DD)
 
2) I performed the services of ________________________________
 
  From _______________________ To _______________________
       (YYYY/MM/DD)      (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)
 

***End of Document***