Employee Declaration Form - Canada

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PROTECTED WHEN COMPLETED - B
IMM 5658 (10-2014) E (DISPONIBLE EN FRANÇAIS - IMM 5658 F)
EMPLOYER DECLARATION
This form should be completed and signed by the prospective *employer or employer representative (not agent or recruiter), and is intended for applications and requests for a work
permit (where the employer is specified) for a foreign national, submitted to a mission overseas, at a port of entry or to the Case Processing Centre in Vegreville, Alberta, where the
occupation does not require a Labour Market Impact Assessment. This form is for the purpose of providing Citizenship and Immigration Canada or the Canada Border Services
Agency with employer information, which will assist in work permit processing under the Temporary Foreign Worker Program.
*For the purposes of this form, an employer or representative is the person authorized to sign contracts/job offers and responsible for ensuring wages, working conditions and/or
occupations are consistent with the terms of the contract/job offer. A representative acting on behalf of an employer must attach written authorization from the employer to act on his/
her behalf; however the employer is still bound by its obligations to honour the terms of the contract/job offer.
TEMPORARY FOREIGN WORKER
Family name Given name(s)
Date of birth (YYYY-MM-DD)
File number/Client ID (if available)
PART 1 - EMPLOYER IDENTIFICATION AND DETAILS
Name of employer/representative* Name of business
Name business operates under (if different) Canada Revenue Agency (CRA) business number
Branch/subsidiary
Business telephone number
Website (if applicable) Contact name
Job title of contact person
Phone number of contact person
Email address of contact person**
Fax number of contact person
Preferred official language
of correspondence
FrenchEnglish
Describe the principal business activity
**NOTE: By indicating your e-mail address, you authorize Citizenship and Immigration Canada to transmit your personal information to that specific e-mail address.
E-communication is our primary method of correspondence.
PART 2 – STATEMENT OF PRIVACY
I understand that employer information provided in support of a work permit application or request pursuant to the Immigration and Refugee Protection Act (IRPA) and Regulations
(IRPR), including information that qualifies as personal information within the meaning of the Privacy Act, as well as any other information collected by Citizenship and Immigration
Canada (CIC), the Canada Border Services Agency (CBSA) or Employment and Social Development Canada (ESDC), will be stored in Personal Information Bank CIC PPU 054,
Temporary Foreign Worker Records and Case File. It is protected and accessible under the Privacy Act and the Access to Information Act.
I understand that the information collected can be shared and used by CIC, CBSA and ESDC, under the Temporary Foreign Worker Program, for the purposes of administering and
enforcing the IRPA and its regulations; and that this information may also be shared with provincial and/or territorial governments for the purposes of the administration and
enforcement of provincial or territorial laws that regulate employment, or the recruiting of employees, in accordance with applicable legislation.
In accordance with the Privacy Act and the Access to Information Act individuals have the right to protection of an access to their personal information. Details on these matters are
available at the Infosource website.
PART 3 – SIGNATURE AND DATE
I understand that non-compliance on the part of the employer of a foreign national in Canada, in relation to rendering wages, working conditions and/or occupation as stated in the
contract or job offer may result in the employer's ineligibility to participate in the Temporary Foreign Worker Program for a period of two years.
I have read and understand my obligations as the primary employer for this job offer, and the information provided on this form is true and accurate to the best of my knowledge.
Signature of Employer/
Representative*
Date (YYYY-MM-DD)
Printed name of employer/
representative
Title
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