CERTIFIED IDENTITY CONFIRMATION

Candidate: I, the undersigned, hereby certify under oath that I am the person named in this Certified Identity Confirmation
document and that the photograph attached hereto is a photograph of me which was taken within six (6) months of the date of
submission of this Certified Identity Confirmation document. I acknowledge that this Certified Identity Confirmation document
shall expire and cease to be valid five years following the date of its acceptance by MCC.

Current legal name (given name(s) and surname): ________________________________________________________

Please print clearly
Date of birth: 19___ ___ / ___ ___ / ___ ___
( yy / mm / dd )
Certifying Official:
I certify that, on the date set forth below, the individual named on this form did appear
personally before me and that I did identify this individual by: (a) comparing his/her
physical appearance with the photograph on the valid government-issued identifying
document(s) presented by the individual and with the photograph affixed hereto, Candidate photo
and (b) comparing the individual’s signatures made in my presence on this form
to be certified:
with the signature on his/her valid government-issued identifying document(s). The
Firmly attach one
statements in this document are subscribed and sworn before me by the individual on photograph here.
this day, in the month of , in the year 20 __ __. See below for photograph
requirements.
In my capacity as:

At:

Name:

Signature:

Telephone:

E-mail:
As the certifying official, your seal, stamp or signature must cover a portion
of the photograph and of the form to the left or right of the photograph.
Candidate’s signature
NOTE: Once completed, this form represents a legal document confirming identity. Any
corrections made to the information entered above must be initialed by the certifying official.

Candidate: Please attach a second identical photograph, which will be scanned

by the MCC and used for examination and/or source verification request purposes,
as applicable. Candidate photo
(DO NOT CERTIFY):
MCC Candidate Code (if available):
Attach a second
identical photograph here
PCRC ID Number (if available):
with one piece of scotch tape
along the top edge.
Photograph Requirements:
Do not tape over the face.
Do not have this photograph
 Must be current, i.e. taken within the past six (6) months. certified or marked.
 Must be colour (black and white photos are not accepted).
 Should be passport-size, approximately 50 mm (2 inches)
wide by 70 mm (2 3/4 inches) long.
 Must be passport-quality, i.e. full-face and very clear with
contrasting background. Scanned photographs are not
passport-quality and therefore not acceptable.
 Must be an original, i.e. not taken from an existing photo.

MCC | Certified Identity Confirmation

Candidate’s signature
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Certifying official’s
contact information.
Mr./Ms. Certifying Official
123 Any Street, Anycity, Anycountry
certifyingofficial@server.com
tel.: 613-555-5555

Certifying Certification
official’s seal MUST include the words
I certify this be a true
or stamp. “true copy of the original”.

L•
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Certifying official’s SIGNATURE.

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L FIC
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DATE of certification.
1, 2013
January
MCC | Certification Sample - Passport