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Use of Representative Form - SAMPLE

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26 views2 pages

Use of Representative Form - SAMPLE

Uploaded by

saurabhnaruka
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PAGE 2 OF 2

7. Your representatlve's contact Information


Name ol firm or o,gamlat,on (1f applicable)
GREEN ANO SPIEGEL, LLP- Evan J. Green
II student-at,law, write Ille name of tho supervismg lawyer SupeMsmg lawyer membership 10
I

Ma,1,ng address
150 York Street, 5th Floor

TORONTO, ONTARIO
PoSlal code/ZIP
M5H 3S5
Telephone number Country CDde Area code Number
(1 ) (416) 862-7880
FaK number Country code Area CD<le Number

(1 ) (416) 862-1698
Ema,1 address(� applicable)
evang@gands.com

By Indicating your representative's e-mail address, you are hereby authorizing Citizenship and Immigration Canada to transmit your file and personal information to this
specific email address.
8. Your representative's declaration:
• I dedare that the information in Section B Is truthful, complete and correct.
• I understand and accept that I am the person appointed by the applicant to conduct business on the applicant or sponso�s behalf with Citizenship and Immigration
Canada and Canada Border Services Agency
Signature of representative

Date

SECTION C: CANCEL THE APPOINTMENT OF A REPRESENTATIVE

I withdraw my authorization for this person to serve as my representative, to receive information on my case file and to conduct business on my behalf with Citizenship and
Immigration Canada and Canada Border Services Agency.
9. Your reprasentatlve's full name
Family name (Surname)

Given name(s)

Name of firm or organlzalion


(ii applicable)

SECTION D: YOUR DECLARATION

10. Your declaratlon


• I dedara that I have fully and truthfully answered all queslions on this form and any attached application (if applicable).
• I also declare that I have read and understood all the stalements on this form, having asked and obtained an explanation for every point that was not dear to me

Signature of applicant
�fkiNT A.s>1c;N � ;;;� pecM1_
Date jl'YYY-MM-001
current Dat ,i

Signature or spouse or common,law partner


for sponsorship appllcalion
<YYYY-MM-001
Date

Warning! It is a serious offence to give false or misleading information on this form.

The Information you provide on this form is collected under the authority of the Immigration and Refugee Protechon Act and the Citizenship Act and will be used in assessing your
application according to the requirements or the Act It will be retained in a Personal Information Bank identified in lnfosource The informalion may be shared with other
organizations such as the Canada Border Services Agency (CBSA), the Royal Canadian Mounted Police (RCMP) the Canadian Security and Intelligence Service (CSIS), where
there is an agreement or arrangement with a foreign government, in accordance with subsection 8(21 of the Privacy Act. Pu($uant to lhe Immigration and Refugee Protection
Regulations and the Citizenship Regulations, the information may also be shared with a regulatory body that is responsible for governing or investigating the conduct or
representatives, such as a provincial and tenitorial law society. the Chambre des Notaires du Quebec and the Immigration Consullants of Canada Regulatory Council (ICCRC)
Under lhe Privacy Act and the Access to Information Act individuals have the right to protection of and access to their personal information. Details on these malters are available
al infosource gc.ca. lnfosource is also avallable In Canadian public libraries.

IMM 5476 (09·2015) E

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