SAMPLE ONLY
DO NOT COMPLETE THIS FORM
CERTIFIED IDENTITY CONFIRMATION
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Certifying official’s
Current legal name (given name(s) and surname): ________________________________________________________
seal or stamp
3OHDVHSULQWFOHDUO\
(in
ENGLISH or
FRENCH) must
cover only a portion
of the photo.
Date of birth: 19___ ___ / ___ ___ / ___ ___
/
mm
/
dd )
At:
Signature:
Email:
Applicants MUST sign here.
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7KHVHDORUVWDPS0867EHLQENGLISH OR FRENCH.
NOTE: 2QFH FRPSOHWHG WKLV IRUP UHSUHVHQWV D OHJDO GRFXPHQW FRQ¿UPLQJ LGHQWLW\ $Q\
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Candidate: Please attach a second identical photograph, which
willleft
be scanned
To be
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BLANK for
as applicable.
STUDENT
applicants.
MCC Candidate Code (if available):
Photograph Requirements:
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Must be colour (black and white photos are not accepted).
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ZLGHE\PPLQFKHVORQJ
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contrasting background. Scanned photographs are not
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0XVWEHDQRULJLQDOLHQRWWDNHQIURPDQH[LVWLQJSKRWR
Second
identical photo
required here
attached with
one piece
of scotch tape.
Applicants MUST sign here.
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All information
must be provided
by the certifying
official.
Name:
Telephone:
See below for photograph
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IAL •
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In my capacity as:
, in the year 20 __ __.
Certifying official must
write the CURRENT date.
CER
T
L•
Y I N G OF
day, in the month of
Firmly attach one
photograph here.
IF
this
Candidate photo
WREHFHUWL¿HG
FIC
( yy
&HUWLI\LQJ2I¿FLDO:
I certify that, on the date set forth below, the individual named on this form did appear
personally before me and that I did identify this individual by: (a) comparing his/her
physical appearance with the photograph on the valid government-issued identifying
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and (b) comparing the individual’s signatures made in my presence on this form
with the signature on his/her valid government-issued identifying document(s). The
statements in this document are subscribed and sworn before me by the individual on
.
Candidate’s signature
Candidate photo
(DO NOT CERTIFY):
Attach a second
identical photograph here
with one piece of scotch tape
along the top edge.
Do not tape over the face.
Do not have this photograph
FHUWL¿HGRUPDUNHG
This second
photo
SHOULD NOT be
certified; ONLY
the above photo.
.
Candidate’s signature
SAMPLE ONLY
DO NOT CERTIFY THIS SAMPLE
CERTIFICATION OF PASSPORT
Certifying official’s
contact information.
Mr./Ms. Certifying Official
123 Any Street, Anycity, Anycountry
[email protected]
tel.: 613-555-5555
Certifying
official’s seal
or stamp
in ENGLISH
OR FRENCH.
EG
Y I N G OF
AL SE
CER
T
L•
IF
A
Certification
MUST include the words
“true copy of the original”.
I certify this be a true
photocopy to ginal
copy of the ori
document
Certifying official’s SIGNATURE.
FIC
IAL •
L
1, 2013
January
MCC | Certification Sample - Passport
DATE of certification.