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Confirmation for Triennial Review

This form is a sample and not intended for printing.

1120-XX:  «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)

Address (residential)

Mailing address (if different)

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