Schedule B - Address Authorization Form (Page 2 of 3) in pdf

ADDRESS AUTHORIZATION FORM

This form must be completed when the applicant for an Alberta Identification Card is currently homeless and cannot provide a physical Alberta address as

required by legislation. In lieu, an applicant may provide the address of a Certified Agency.

CERTIFICATION BY THE APPLICANT

APPLICANT’S FIRST NAME

MIDDLE NAME OR INTIAL

LAST NAME

DATE OF BIRTH

ALBERTA STREET ADDRESS

CITY

PROVINCE

POSTAL CODE

I certify that I am the person described above, that I am a resident of the province of Alberta, that I do not have documentary proof of an Alberta street address, that I am

authorized to use the Certified Agency’s address to receive mail and legal notices, and I request that the address above be entered as my address on any Alberta Identification

Card issued to me.

By signing this form, I hereby authorize the Minister of Human Services to collect this information under Section 34(1)(a)(i) of the FOIP Act for the purpose of carrying out a

program, activity or policy under his administration.

WARNING: This document is part of an application for an Alberta Identification Card. It is a criminal offense to falsify information when applying for an

Alberta Identification Card.

APPLICANT’S SIGNATURE:

___________________________________

DATE: _________________________________

CERTIFICATION BY THE CERTIFIED AGENCY

NAME OF CERTIFIED AGENCY

ADDRESS OF THE CERTIFIED AGENCY

CITY

PROVINCE

POSTAL CODE

NAME OF THE CERTIFIER

TELEPHONE NUMBER

FAX OR EMAIL ADDRESS (Optional)

(

)

I certify that I am a Certifier of the above Certified Agency, that to the best of my knowledge and belief the applicant is a resident of the province of Alberta and does not have

documentary proof of an Alberta street address, and that the applicant can receive mail and legal notice at the Certified Agency’s address listed above.

WARNING: It is a criminal offense to knowingly assist an individual with fraudulently obtaining an Alberta Identification Card.

CERTIFIER’S SIGNATURE:

___________________________________

DATE: ________________________

NAME OF THE CERTIFIED AGENCYS CEO or DESIGNATE

TELEPHONE NUMBER

EMAIL ADDRESS

(

)

I certify that I am the CEO or designate of the above Certified Agency and that to the best of my knowledge the Certifier has done adequate due diligence in verifying that the

applicant is a resident of the province of Alberta and does not have documentary proof of an Alberta street address.

WARNING: It is a criminal offense to knowingly assist an individual with fraudulently obtaining an Alberta Identification Card.

CERTIFYING AGENCY’S CEO OR DESIGNATE’S SIGNATURE:

__________________________

DATE: ________________________

The personal information on this form is being collected under the authority of Sections 33 (c) of the Freedom of Information and Protection of Privacy

(FOIP) Act and in accordance with any applicable agreements in place between this agency and the Minister of Human Services, for the purpose of

providing the applicant with personal identification services. It will be treated in accordance with the privacy provisions of Part 2 of the FOIP Act and in

accordance with any applicable agreements in place between this agency and the Minister of Human Services. If you have any questions, contact

Homeless Program Policy Integration, Ministry of Human Services 403-297-3368 (toll free by dialing 310-0000 first).

Form: HUA_001