Use of A Representative

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USE OF A REPRESENTATIVE
You do not need to hire a representative, it is your choice. No one can guarantee the approval of your application. All the forms and information that you need
to apply are available for free at www.cic.gc.ca.
A representative is someone who has provided advice or guidance to you at any stage of the application process, whether that person received consideration
(i.e. compensation) or not. Following the submission of your application, that person may conduct business on your behalf with Immigration, Refugees and
Citizenship Canada (IRCC) and the Canada Border Services Agency (CBSA) if you appoint them as your representative by filling out this form. The preceding
includes Express Entry submissions. You may have one representative only per application. If you appoint an additional representative, the previous
representative will no longer be authorized to conduct business on your behalf and receive information on your case file.
Note: You must use this form to appoint a paid or unpaid representative to conduct business with IRCC or the CBSA on your behalf. You must also use this
form to: 1. notify IRCC if your representative's contact information changes, 2. if you wish to cancel the appointment of your current representative and
represent yourself, or, 3. if you wish to cancel the appointment of your current representative and appoint a new representative
I am:
✔ appointing a representative. Complete Sections A, B and D.
cancelling the appointment of a representative. Complete Section A, C and D.
SECTION A: APPLICANT INFORMATION

1. Your full name
Family name (Surname) Given name(s)
Jebamani Samuel Joshua Daniel
2. Your date of birth (YYYY-MM-DD)
1986-12-30
3. If you have already submitted your application:
Name of office where the application was submitted Type of application (permanent residence,extension of study permit, etc.)
4. Unique Client Identifier (UCI) number (if known)
SECTION B: APPOINTMENT OF REPRESENTATIVE

• I authorize the following individual to serve as my representative and to conduct business on my behalf with Immigration, Refugees and Citizenship
Canada and Canada Border Services Agency. Note: Even if a representative is being paid or compensated by someone other than you (the applicant),
the representative is still considered to be a compensated representative.
• I authorize Immigration, Refugees and Citizenship Canada and Canada Border Services Agency to release information from my case file and that of my
dependent children under 18 years of age to my representative. This authorization is in accordance with the Privacy Act.
• I am aware that any information which would be subject to exemption, if I had the right of access under the Privacy Act or the Access to Information Act,
will likely not be released.
5. Your representative's full name
Indrawati Pipin
6. Your representative (tick one box):

(i) is UNCOMPENSATED and is a
friend or family member

member of the Immigration Consultants of Canada Regulatory Council (ICCRC), a Canadian provincial or territorial law society, or the Chambre des
notaires du Québec
Which province or territory? Membership ID number
other (please specify)
IMM 5476 (10-2021) E (DISPONIBLE EN FRANÇAIS - IMM 5476 F)

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OR
(ii) is, or will be, COMPENSATED and is a member in good standing of
the Immigration Consultants of Canada Regulatory Council (ICCRC)

Membership ID number
a Canadian provincial or territorial law society

Which province or territory? Membership ID number
the Chambre des notaires du Québec

Membership ID number
7. Your representative's contact information

Name of firm or organization (if applicable)
If student-at-law, write the name of the supervising lawyer Supervising lawyer membership ID
Mailing address
Apt/Unit Street no. Street name
City/Town Province/State/Territory Country or territory Postal code/ZIP
Telephone number
Country Code Area Code and Telephone number
Fax number
Country Code Area Code and Telephone number
E-mail address (if applicable)
By indicating your representative's e-mail address, you are hereby authorizing Immigration, Refugees and Citizenship Canada to transmit your file and
personal information to this specific email address.
8. Your representative's declaration:
• I declare that the information in Section B is truthful, complete and correct.
• I understand and accept that I am the person appointed by the applicant to conduct business on the applicant or sponsor's behalf with Immigration,
Refugees and Citizenship Canada and Canada Border Services Agency.
Signature of representative Date (YYYY-MM-DD)

SECTION C: CANCEL THE APPOINTMENT OF A REPRESENTATIVE
I withdraw my authorization for this person to serve as my representative, to receive information on my case file and to conduct business on my behalf with
Immigration, Refugees and Citizenship Canada and Canada Border Services Agency.
9. Your representative's full name
Name of firm or organization (if applicable)
IMM 5476 (10-2021) E

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SECTION D: YOUR DECLARATION

10. Your declaration
• I declare that I have fully and truthfully answered all questions on this form and any attached application (if applicable).
• I also declare that I have read and understood all the statements on this form, having asked and obtained an explanation for every point that was not
clear to me.
2021-10-17
Signature of applicant Date (YYYY-MM-DD)
2021-10-17
Signature of spouse or common-law partner for sponsorship application Date (YYYY-MM-DD)
Warning! It is a serious offence to give false or misleading information on this form.
Personal information provided on this form is collected by Immigration, Refugees and Citizenship Canada (IRCC) under the authority of the Immigration and
Refugee Protection Act (IRPA) and of the Citizenship Act. The personal information of the applicant is used for identification and authorization purposes. The
personal information of the immigration representative is used to verify that the representative is authorized to offer representation services according to the
provisions of IRPA and of the Citizenship Act.
The personal information of both the applicant and the representative may be disclosed to other federal government institutions, non-governmental and inter-
governmental organizations, regulatory bodies, investigative bodies, and provincial/territorial governments for the purposes of validating identity, information,
and supporting an investigation.
Personal information of both the applicant and the representative may be used for other purposes including research, statistics, program and policy evaluation,
internal audit, compliance, risk management, strategy development and reporting.
Failure to complete the form in full will result in a delay to processing. The Privacy Act gives individuals the right of access to, protection, and correction of
their personal information. If you are not satisfied with the manner in which IRCC handles your personal information, you may exercise your right to file a
complaint to the Office of the Privacy Commissioner of Canada. The collection, use, disclosure and retention of your personal information is further described
in IRCC's Personal Information Bank - IRCC PPU 013, 042, 054, 068.
IMM 5476 (10-2021) E

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PROTECTED WHEN COMPLETED - B

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✔ appointing a representative. Complete Sections A, B and D.

cancelling the appointment of a representative. Complete Section A, C and D.

SECTION A: APPLICANT INFORMATION

Jebamani Samuel Joshua Daniel

2. Your date of birth (YYYY-MM-DD)

4. Unique Client Identifier (UCI) number (if known)

SECTION B: APPOINTMENT OF REPRESENTATIVE

6. Your representative (tick one box):

friend or family member

other (please specify)

IMM 5476 (10-2021) E (DISPONIBLE EN FRANÇAIS - IMM 5476 F)

the Immigration Consultants of Canada Regulatory Council (ICCRC)

a Canadian provincial or territorial law society

the Chambre des notaires du Québec

7. Your representative's contact information

City/Town Province/State/Territory Country or territory Postal code/ZIP

E-mail address (if applicable)

Signature of representative Date (YYYY-MM-DD)

Name of firm or organization (if applicable)

IMM 5476 (10-2021) E

SECTION D: YOUR DECLARATION

Warning! It is a serious offence to give false or misleading information on this form.

IMM 5476 (10-2021) E

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