Visa Services Canada Form Page 5
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VISA SERVICES CANADA
Suite 900 - 275 Slater St.
Ottawa, ON, K1P 5H9, CANADA
W W W .VISASERVICESCANADA.CA
613-231-7054
I, ___________________________________, authorize Visa Services Canada to act on my behalf in acquiring a
visa for my passport. Visa Services Canada is authorized to drop-off and pick-up my passport and any other
personal documents from the embassy, high commission, consulate, diplomatic mission of the country of
__________________________ while aiding me in acquiring a visa. Visa Services Canada is also authorized to
BANGLADESH
receive information about my application from the visa office while acting on my behalf.
Signed on this _____ day of the month of _____________ in the year ______,
20
in the city of ___________________ in the province of __________________, in Canada.
Signature_________________________________________
OFFICE COPY
------------------------------------------------------------------------------------------------------------------------------------------
VISA SERVICES CANADA
Suite 900 - 275 Slater St.
Ottawa, ON, K1P 5H9, CANADA
W W W .VISASERVICESCANADA.CA
info@visaservicescanada.ca
613-231-7054 toll-free 866-378-1229
I, ___________________________________, authorize Visa Services Canada to act on my behalf in acquiring a
visa for my passport. Visa Services Canada is authorized to drop-off and pick-up my passport and any other
personal documents from the embassy, high commission, consulate, diplomatic mission of the country of
__________________________ while aiding me in acquiring a visa. Visa Services Canada is also authorized to
BANGLADESH
receive information about my application from the visa office while acting on my behalf.
Signed on this _____ day of the month of _____________ in the year ______,
20
in the city of ___________________ in the province of __________________, in Canada.
Signature_________________________________________
EMBASSY COPY
TYPE ON SCREEN
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