Designated Party Authorization Form

October 2024

This form is available as a PDF (Portable Document Format). This HTML document is not a form. Its purpose is to display the information as found on the form for viewing purposes only. If you wish to use the form, you must use the alternate format below.

(PDF Version)

Protected when completed

Note: Only submit this document with the application when the party signing the application is a designated party acting on behalf of the petitioner. A separate authorization is required for each application.

I (The Senior Official) authorize (Third party person) of (Third party company name) to file a submission with the Food and Nutrition Directorate on behalf of (Applicant/Company name)

• Signature:
• Print Name:
• Title:
• Applicant/Company name:
• Date (yyyy-mm-dd):

Contact information

• Surname:
• Mr.
• Ms.
• Dr.
• Given Name:
• Title:
• Language preferred
  • English
  • French
• Street/Suite/Land Location:
• City - Town:
• Province - State:
• Country:
• Postal/ZIP Code:
• Telephone No.:
  • Ext.:
• Fax No.:
• E-mail: