l*l Citizenship and Citoyennet6 et
ImmigrationCanada lmmigrationCanada
PROTECTED WHEN COMPLETED - B
PAGE 1 OF 1
USE OF A FAMILY MEMBER REPRESENTATIVE
FOR ONLINE APPLICATIONS
This form is for family members who wish to apply online together in one MyCIC submission. To do so, all members must complete this form (one per family) to appoint
the family member wlrose MyCIC account will be used to submit the applications.
NOTE: lf you appoint a family member as a representative, that person will be authorized to conduct business on your behalf and receive information on your case file.
SECTION A - FAMILY MEMBER REPRESENTATIVE
Write the full name and date of birth of the family member to be appointed as representative
Full name Date of birth (YYYY-MM-DD)
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Family name (Surname) Given name(s)
JAWANDHA HARMINDER SINGH
1 97 7 -0 9-0s
3 | lnformation on the tamily members
Write name, date of birth and define the relationship (e.9. spouse, son. daughter, etc.) of each family membe. to the representative.
Family Relalionship to Date of birth
Name
member iamily member representalive ([Link])
1 RAVINDER XAUR .]AWANDHA SPOUSE 197 4-02 -0 3
2 SUKHMANVIR KAUR DAUGHTER 2400-41 -21
3 DHANVTR SINGH soN 2005-10-10
SECTION B. GRANTING PERMISSION TO THE FAMILY MEMBER REPRESENTATIVE
Each family member 18 years of age and older listed in Section A must sign and date this section to appoint the family
member chosen to represent them
By signing Seclion B, I hereby give permission to the family member representative listed in Section A to submit the application, conduc{ business and receive information
on my behalf. I declare that the information on this form and on the application that I have authorized my family member to submit on my behalf is truthful, complete and
correcl.
Family Date
Signature
member (YYYY-MM-DD)
'l HARI'{INDER SINGH 2422-45-49
IMPORTANT:
Once permission is given to your spouse or mmmon-law partner or parent, the only way to revoke approval is to cancel the application and resubmit. The
application fes will not be refunded and fees will have to be paid again for another appli€tion.
Note: This permission applie8 to dependent children 18 years of age and older. Those under the age of 18 do not have to provide approval.
SECTION C. DECLARATION OF FAMILY MEMBER REPRESENTATIVE
I declare that the information I have given is truthful, complete and correct.
?
a Date
(YYYY-MM-DD)
2022-05-09
Warning! lt is a serious offence to give false or misleading information on this form.
Agency (CBSA), the Royal Canadian Mounted Police (RCMP), the Canadian Searity and lntelligen@ Seruie (CSIS), whee there is an agreemenl or amngement wth a foreign govemment,
in ac@rdan@ with subsection 8(2) of the Pivacy Ac. Pureuant to lhe lmmigation and Refug@ Prcteclion Regulatioas, the infomation may also be shared wth a regulator body that is
these matters are available at [Link].a and through the Citizenship and lmm,gration Call Centre. lnfcource is also available in Canadian public libraries-
This form is made available by Citizenship and lmmigration Canada and is not to be sold to applicants.
IMM 571X (12-2A12)E (AUSSI DISPONIBLE EN FRANQAIS - IMM 5713 F) Canad?i
