Schedule A - Appointment Form Of A Third-Party Representative Page 3

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DECLARATION OF EMPLOYER

FOR THE PURPOSE OF THIS LABOUR MARKET IMPACT ASSESSMENT APPLICATION:

, located at

(Name of employer)

(Complete employer business address)

Telephone Number:

Fax number:

and I

, located at

(Name of employer number 2, if applicable)

(complete employer address of employer number 2, if applicable)

Telephone Number:

Fax number:

hereby appoint the third-party indicated on this form as my representative to act on my behalf in order to obtain a Labour Market Impact Assessment from

ESDC/Service Canada to hire

(Name of the foreign worker to whom the offer of employment has been made or is anticipated to be made)

I, hereby, agree to ratify and confirm all that my third-party representative shall do or cause to be done by virtue of this appointment.

This appointment shall remain in full force and effect only for the processing of this application, unless due notice in writing of its revocation has been given to

ESDC/Service Canada.

Date (YYYY-MM-DD)

Signature of employer

Printed name of employer

Date (YYYY-MM-DD)

Signature of employer number 2 (if applicable)

Printed name of employer number 2

Date (YYYY-MM-DD)

Signature of witness

Printed name of witness

ESDC EMP5575 (2015-08-005) E

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