Schedule A - Appointment Form Of A Third-Party Representative

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Employment and

Emploi et

PROTECTED WHEN COMPLETED - B

Social Development Canada

Développement social Canada

SCHEDULE A

APPOINTMENT OF A THIRD-PARTY REPRESENTATIVE

Personal Information Collection Statement

The information you provide on this form is collected by Employment and Social Development Canada (ESDC) under the authority of the Immigration and

Refugee Protection Act (IRPA) and Immigration and Refugee Protection Regulations (IRPR), for the purpose of providing a Labour Market Impact Assessment

(LMIA) in accordance with these statutes. Completion is voluntary; however, failure to complete this form will result in your LMIA application not being processed.

The information you provide may be shared with Citizenship and Immigration Canada (CIC) for the administration and enforcement of the IRPA and IRPR as

permitted by the Department of Employment and Social Development Act (DESD Act), and may be accessed by the Canada Border Services Agency (CBSA) for

the purpose of issuing work permits at Ports of Entry. ESDC may also provide information to CBSA in order for that agency to investigate and enforce the IRPA

and IRPR in relation to an LMIA.

The information may also be shared with provincial/territorial governments for the purpose of administration and enforcement of provincial/territorial legislation,

including employment standards and occupational health and safety legislation, as permitted by the DESD Act. The information may also be used by ESDC for

inspections, policy analysis, research and evaluation in relation to the entry and hiring of TFWs to Canada or the IRPA.

The information you provide is administered under Part 4 of the DESD Act and the Privacy Act. You have the right to access and request correction of your

personal information, which is described in Personal Information Bank PPU 440 and PPU 171 of Info Source. Instructions for making formal requests are outlined

in the Info Source publication available online at

infosource.gc.ca.

THIRD-PARTY BUSINESS INFORMATION

1. Business Operating Name of Third-Party:

2. Canada Revenue Agency Business Number

(first 9 digits are mandatory for Canadian businesses):

3. Legal Name:

4. Third-party ID number (if applicable):

5. Mailing Address:

6. City:

7. Province/State:

8. Country: