Third Party Representative Authorization Form
Canada Community Security Program (CCSP)

A third party representative is an individual or entity retained by the organization for the specific purpose of acting on behalf of the organization. A person who works directly for the organization or is part of its staff is not considered a third-party representative.

For the purposes of this application, the organization's representative is an individual or entity that has been granted specific signing authority and authority to conduct business on behalf of the organization.

Following submission of the application, the organization understands and agrees that the appointed third party representative will be allowed to conduct business on behalf of the organization with Public Safety Canada. Public Safety Canada will not consider having the required legal authority to deal with your chosen third party representative if this form has not been submitted.

This form not only confirms your appointment of a third-party representative but also authorizes Public Safety Canada to transmit the content of your file and any and all information (both personal and other) to the contact person identified in this form.

You are not required to use a third party representative, that decision is entirely up to you. Please note that no one can guarantee the approval of your application. The application guide provides all the details on how to complete the application form and the forms and templates are available on the Canada Community Security Program website.

Section A: Organization's information

• Name of the organization
• Full name of the organization's representative
  Family name(surname)
  Given name(s)
• Position/Title
• Daytime Telephone number

Section B: Appointment of a third-party representative

• I, the organization's representative, have authorized the individual or entity that is applying for this funding to apply on the organization's behalf;
• I, the organization's representative, am in agreement with all of the information that is provided in the application, and;
• I, the organization's representative, understand that even if I am authorizing Public Safety Canada to deal with my chosen third party representative, I will nevertheless be required to sign the contribution agreement myself on behalf of my organization and cannot have my chosen third party representative sign on my behalf. I further recognize that even if subsequent contact is done through my chosen third-party representative, my organization remains bound by all of the terms and conditions of the contribution agreement.

• Third party representative's information
  Family name (surname)
  Given name(s)
  Name of firm or organization (if applicable)
  Telephone number
  E-mail address

Section C: Your declaration

• I declare that I have fully and truthfully answered all questions on this form.
• 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.

Signature :
Date (YYYY-MM-DD) :

Information provided by applicants is subject to the Access to Information Act (R.S.C., 1985, c. A-1) and the Privacy Act (R.S.C., 1985,c. P-21). Information provided is collected by Public Safety Canada under the authority of the Department of Public Safety and Emergency Preparedness Act (S.C. 2005, c. 10) for the purpose of supporting the implementation of projects. The information collected in this application will be used, and may be disclosed, for the purpose of assessing the eligibility/merits of your application's evaluation. Information that you provide may be shared with external consultants, review committee members, officials in other Departments, Federal, Provincial and/or Territorial Governments or Members of Parliament. It may also be used and/or disclosed for policy analysis, research and/or evaluation purposes in order to conduct these activities.

For more information about the collection, use and retention of your personal information, refer to the following Personal Information Bank: National Crime Prevention Strategy, Bank number PS PPU 020, PS Info Source.

Please note, these additional uses and/or disclosures of information will not impact your project. You have the right to the protection of, access to and correction of your personal information. Instructions for obtaining this information are outlined on the Public Safety Canada Access to Information and Privacy (ATIP) website.

Any questions, comments, concerns or complaints you may have regarding Public Safety Canada's handling of your personal information may be directed to our Access to Information and Privacy team by email: atip-aiprp@ps-sp.gc.ca. If you are not satisfied with Public Safety Canada's response to your privacy concern, you have the right to file a complaint with the Privacy Commissioner of Canada regarding the institution's handling of your personal information.