Schedule A - Appointment Form Of A Third-Party Representative Page 2

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THIRD-PARTY CONTACT INFORMATION (Authorized representative acting on behalf of the employer )
1.
First name
Middle name
Last Name:
2. Job title:
3. Telephone Number
Ext:
4. Fax Number:
5. E-mail Address:
6. Preferred Official Language of Correspondence:
English
French
7. Indicate which one of the following applies to the third-party representative
The representative is UNPAID and is:
a family member or a friend
a member of a non-governmental or a religious organization
a member in good standing of the Immigration Consultants of Canada Regulatory Council (ICCRC), a provincial or territorial law society or the
Chambre des notaires du Québec
other (please describe):
Note:
UNPAID third-party representatives are not eligible for the TFW Web Service
8. The representative is, has been, or will be PAID and is a member in good standing of:
the Immigration Consultants of Canada Regulatory Council (ICCRC)
MEMBERSHIP ID:
a provincial/territorial law society
PROVINCE/TERRITORY:
MEMBERSHIP ID:
the Chambre des notaires du Québec
MEMBERSHIP ID:
other (please describe):
DECLARATION OF THE THIRD-PARTY REPRESENTATIVE
I, hereby, declare that the above information is true, accurate and complete.
Signature of the Third-party Representative
Printed name of the Third-party Representative
Date (YYYY-MM-DD)
ESDC EMP5575 (2015-08-005) E
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