Triennial Confirmation

1120-Code-«Member_Number»

Full name of the political party:

I am the individual whose name and address appear on the attached declaration.

I hereby confirm that I have signed the attached declaration and that I am a member of the political party named above.

 Yes / No

Surname

Given name(s)

Mailing address

City |Prov.| Postal Code

I hereby confirm that Elections Canada may share the personal information supplied on this form with the above named political party.

 Yes / No

Signature 

Date

Privacy statement

The personal information supplied on this form is collected under the authority of the Canada Elections Act for the purpose of administering the registration of political entities. The information is available for public inspection in accordance with the Act, and certain information is published on the Elections Canada website at www.elections.ca. You have a right to access and/or to request a correction of your personal information under the Privacy Act. For details on the collection and use of this information, consult the entry for Personal Information Bank CEO PPU 036 at www.infosource.gc.ca.