Canadian Radio-television and Telecommunications Commission | Conseil de la radiodiffusion et des télécommunications canadiennes
 

Symbol of the Government of Canada
 

Canadian Program Certification

Declaration of Citizenship or Permanent Resident

SCHEDULE 4

 

I hereby certify and confirm that:
 
1) I am (please check one)
 
  a) Canadian citizen
 
   i) by birth
 		 (  )
   ii) by naturalization
 		 (  )
     (Date of naturalization: _________________)
                                 (year/month/day)
 
OR
 
  b) a permanent resident of Canada within the meaning of the Immigration Act (  )
 
   (Date of admission as a permanent resident: _________________)
                                                                (year/month/day)
 
2) I performed the services of ________________________________
 
  from _________________________
       (year/month/day)		 to ____________________________
   (year/month/day)
 
  on the production entitled: ______________________________________
 
3) My present address is:
 
  _______________________________
(apt./number/street)		 _______________________________
(city/town)
 
  _______________________________
(province)		 _______________________________
(code postal)
 
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
 

Print (surname)
 
(first name)
_________________________
(signature of applicant)
 		 ______________________________
(date)


This document is available in alternative format upon request.
CRTC - Schedule 4 (2006-01-04) - Canadian Program Certification - Declaration of Citizenship or Permanent Resident

version française disponible

 

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