Declaration of Citizenship or Permanent Resident - Appendix 4

Canadian Program Certification

I hereby certify and confirm that:

1. I am (please check one)

   1. Canadian citizen

      1. by birth ( )

      2. by naturalization ( )

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

      OR

   2. 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 _________________________
   (YYYY/MM/DD)

   to ____________________________
   (YYYY/MM/DD)

   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

CRTC - Appendix 4 (2011-09-01) - Canadian Program Certification - Declaration of Citizenship or Permanent Resident

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