Appendix 3 - Declaration of Citizenship or Permanent Resident

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) Date of naturalization: _________________
      (YYYY/MM/DD)

      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

      ***End of Document***

      Date modified: 2017-02-06