4179 ATT04 - Signing Officers FormHuman Resources and Ressources humaines et PROTECTED WHEN COMPLETED - B
Skills Development Canada Developpement des competences Canada Official use Only
File Number and Organaabon
SIGNING OFFICERS FORM
CONTRIBUTION AGREEMENT
NOTICE TO SIGNATORIES
The information provided is collected under the authority of the Department of Human Resources
and Skills Development Act and the Department of Social Development Act. The information in this
Signing Officers Form will be used and may be disclosed for the purposes of validating the identity
of individuals within the applicant organization having the authority to sign agreements, cheques,
payment claims and reports. Signatories to this form may be asked to provide additional
information and/or documentation confirming their respective identities and roles within the recipient
organization. This form is also to be used to support claim payments and monitoring throughout the
project life cycle.
Completion of this form is voluntary; however, refusal to provide information will result in the
applicant not being considered for funding.
The information provided may be shared with external consultants, review committee members,
officials in other departments, federal, provincial and/or territorial governments or Members of
Parliament for the purpose of review and verification.
The information provided may be used and/or disclosed for policy analysis, research and/or
evaluation purposes. In order to conduct these activities, various sources of information under the
custody and control of Human Resources and Skills Development Canada (HRSDC) may be linked.
However, these additional uses and/or disclosures of personal information will never result in an
administrative decision being made about an individual.
Personal information gathered in this form and/or made available to HRSDC for further
identification purposes, will be administered in accordance with the Privacy Act and the provisions
governing the protection of personal information that are set out in the Department of Human
Resources and Skills Development Act and the Department of Social Development Act, as
applicable. The Privacy Act provides every person with a right to the protection of, and access to
their personal information, which is described in Personal Information Bank(s) HRSDC PPU 298
CERTIFICATION
The Persons providing a specimen signature within this form, in so signing certify as follows:
a) that I am the person with the name indicated alongside my specimen signature;
b) that I will make available to Human Resources and Skills Development Canada, upon their
request, the necessary documentation for the purposes of further identification, and,
C) that I hold the title listed below and, in this capacity, am authorized to sign on behalf of the
applicant organization in accordance with the organization's incorporating documents, bi-
laws, or other relevant documents.
Section 1: Signing Officers for Agreement Purposes
According to Letters, Patents or Other Incorporating Documents)
Please provide the name, title and specimen signature of the person(s) authorized to
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How many of the above signatures are required to bind your organization onto a legal agreement? A
HRSDC EMP5567 (2013-02-001) E Page 1 of 2 Canada
Section 2: Signing Officers for Cheque purposes on behalf of your organization.
Please provide the name, title and specimen signature of the person(s) authorized to sign.
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How many signatures are required to sign a cheque on behalf of your organization? 7. 1
Section 3: Signing Officer for Claims, Forecast of Project Expenditures (FPE) or Activity Report
submitted to HRSDC.
Please provide the name, title and specimen signature of the person(s) authorized to sign.
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How many signatures are required to sign a claim, forecast of project expenditures or activity
reports submitted to HRSDC?
HRSDC EMP5567 (2013-02-001) E Page 2 of 2