stock option plan of microcell dated may 1, 2003



 



Exhibit 4.5


STOCK OPTION PLAN



OF



MICROCELL TELECOMMUNICATIONS INC.



May 1, 2003





 






 





TABLE OF CONTENTS




	 	 	 	 	 	 	 
	1.	 	INTERPRETATION	 	1
	 	 	
1.1.
	 	Definitions
	 	1
	 	 	
1.2.
	 	Headings and References
	 	2
	 	 	
1.3.
	 	Extended Meanings
	 	2
	 	 	
1.4.
	 	Currency
	 	2
	 	 	
1.5.
	 	Governing Law
	 	2
	 	 	
1.6.
	 	Schedules	 	3 
	2.	 	ESTABLISHMENT OF THE PLAN
	 	3
	 	 	
2.1.
	 	Establishment
	 	3
	 	 	
2.2.
	 	Purpose
	 	3
	 	 	
2.3.
	 	No Employment Rights
	 	3
	3.	 	GRANT OF OPTION
	 	3
	 	 	
3.1.
	 	Grant
	 	3
	 	 	
3.2.
	 	Delegation
	 	4
	 	 	
3.3.
	 	Limitations on Grant
	 	4
	 	 	
3.4.
	 	Exercise Price
	 	4
	 	 	
3.5.
	 	No Payment on Grant
	 	4
	 	 	
3.6.
	 	Option Agreement
	 	5
	 	 	
3.7.
	 	Changes in Shares	 	5 
	 	 	
3.8.
	 	Fractional Shares
	 	5
	 	 	
3.9.
	 	Designation of Subsidiary
	 	5
	4.	 	EXERCISE OF OPTIONS
	 	6
	 	 	
4.1.
	 	Exercise of Options
	 	6
	 	 	
4.2.
	 	Vesting of Options
	 	6
	 	 	
4.3.
	 	Death of Participant
	 	6
	 	 	
4.4.
	 	Termination of Service
	 	6
	 	 	
4.5.
	 	Order of Exercise
	 	7
	 	 	
4.6.
	 	Method of Exercise and Class of Shares
	 	7
	 	 	
4.7.
	 	Option Not Transferable
	 	7
	 	 	
4.8.
	 	Permitted Assignments
	 	7
	5.	 	TERMINATION OF OPTION
	 	8
	 	 	
5.1.
	 	Expiration of Exercise Period
	 	8
	 	 	
5.2.
	 	Bankrupt Participant
	 	8
	6.	 	GENERAL
	 	8
	 	 	
6.1.
	 	Delivery of Shares, etc.
	 	8
	 	 	
6.2.
	 	Issuance of Shares
	 	8
	 	 	
6.3.
	 	Administration
	 	8
	 	 	
6.4.
	 	Incapacity
	 	8
	 	 	
6.5.
	 	Amendment and Termination
	 	9
	 	 	
6.6.
	 	Approvals
	 	9
	 	 	
6.7.
	 	Reorganization
	 	9



 






 






	1.	 	INTERPRETATION
	 
	1.1.	 	Definitions




	 	(a)	 	Board means the board of directors of the Corporation.
	 
	 	(b)	 	Business Day means a day, other than Saturday, Sunday or a
statutory holiday, on which banks are generally open for business in
Montreal, Québec and Toronto, Ontario.
	 
	 	(c)	 	Canadian means a Canadian within the meaning ascribed to such
term in the Telecommunications Act (Canada) S.C. 1993, c. 38 and the
regulations thereunder, as amended from time to time.
	 
	 	(d)	 	Change in Control means any of the following occurrences:
(a) the acquisition by any one shareholder, or group of shareholders
acting jointly or in concert, of more than 50% of the outstanding
voting shares of the Corporation; (b) a sale by the Corporation of
all or substantially all of its assets to an unrelated third party,
or other liquidation or dissolution; (c) a change in the composition
of the Board involving at least one-half of the Board which occurs
at the same time or within a 60 day period; or (d) a merger,
consolidation, or other reorganization of the Corporation which
results in the Corporation’s shareholders owning less than 50% of
the voting shares of the resulting entity.
	 
	 	(e)	 	Class A Shares means the Class A Restricted Voting Shares in
the capital of the Corporation.
	 
	 	(f)	 	Class B Shares means the Class B Non-Voting Shares in the
capital of the Corporation.
	 
	 	(g)	 	Corporation means Microcell Telecommunications Inc., a
corporation existing under the laws of Canada and any successor
corporation.
	 
	 	(h)	 	Employee means a person in the full-time or part-time employ
of the Corporation or a Subsidiary, including an officer of the
Corporation or a Subsidiary.
	 
	 	(i)	 	Exercise Price of an Option has the meaning given to it in
Section 3.4(a).
	 
	 	(j)	 	Family Member means a Participant’s spouse, minor child or
minor grandchild.
	 
	 	(k)	 	Market Price of an Option means the greater of the closing
price of the Class A Shares or the closing price of the Class B
Shares, as the case may be, on the TSX or any other stock exchange
on which the shares are listed, on the last trading day immediately
preceding the date of grant of the Option (or if no Shares of any
particular class were traded, the average, rounded up to the nearest
cent, of the bid and ask prices for the Shares of such class at the
close of trading on such day).
	 
	 	(l)	 	Option means a right to subscribe for one or more Shares
pursuant to this Plan.



 






 






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	 	(m)	 	Option Agreement means the written agreement between the
Corporation and a Participant evidencing the grant and acceptance of
an Option substantially in the form of Schedule A.
	 
	 	(n)	 	Participant means an Employee who has been granted an Option.
	 
	 	(o)	 	Plan means this stock option plan including the Schedules, as
amended from time to time.
	 
	 	(p)	 	Service Termination Date means the date on which a person
ceases to be an Employee. For greater certainty, a person ceases to
be an Employee at the time he/she is no longer obligated to work
under the direction or control of the employer even if he/she may
continue to receive payments from the employer as indemnity in lieu
of notice of termination or otherwise.
	 
	 	(q)	 	Shares means Class A Shares or Class B Shares, as determined
by the Board in accordance with Section 4 of this Plan.
	 
	 	(r)	 	Subsidiary of the Corporation at a particular time means a
corporation that is controlled, directly or indirectly, by the
Corporation and is designated as a “Subsidiary” by the Board for the
purpose of this Plan.
	 
	 	(s)	 	TSX means the Toronto Stock Exchange, a division of TSX Inc.
through which the senior listing operations of TSX Group Inc. are
conducted.




	1.2.	 	Headings and References
	 
	 	 	The division of this Plan into sections and the insertion of headings and
a table of contents are for convenience of reference only and shall not
affect the construction or interpretation of this Plan.
	 
	1.3.	 	Extended Meanings
	 
	 	 	Unless otherwise specified, words importing the singular include the
plural and vice versa and words importing gender include all genders.
	 
	1.4.	 	Currency
	 
	 	 	All references to currency or dollar amounts in this Plan are to lawful currency of Canada.
	 
	1.5.	 	Governing Law
	 
	 	 	This Plan shall be governed by and interpreted in accordance with the
laws of Québec and the laws of Canada applicable therein, and the
Corporation and the Participants irrevocably attorn to the non-exclusive
jurisdiction of the courts of Québec.



 






 






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	1.6.	 	Schedules
	 
	 	 	The following Schedules are annexed to this Plan and form part of this Plan:




	 	 	 
	Schedule A	 	
Option Agreement
	Schedule B	 	
Notice
	Schedule C	 	
Residency Declaration




	2.	 	ESTABLISHMENT OF THE PLAN
	 
	2.1	 	Establishment
	 
	 	 	The Corporation hereby establishes this Plan, effective on May 1, 2003.
	 
	2.2.	 	Purpose
	 
	 	 	The purpose of this Plan is to advance the interests of the Corporation
by providing Employees with a financial incentive for the continued
improvement in the performance of the Corporation and encouragement to
continue employment with the Corporation or a Subsidiary, as the case may
be.
	 
	2.3.	 	No Employment Rights
	 
	 	 	Participation in this Plan does not give any Employee the right to
continue as an employee of the Corporation or a Subsidiary or any right
to, or interest in, any Option or Share, except as specifically provided
in this Plan. Nothing in this Plan or in any Option shall be deemed,
interpreted or construed to constitute an agreement, or an expression of
intent, on the part of the Corporation or a Subsidiary, to extend the
employment of any Employee beyond the time at which such Employee would
normally be required to retire in accordance with any applicable
employment agreement, or retirement plan or policy of the Corporation or
a Subsidiary, then in effect.
	 
	3.	 	GRANT OF OPTION
	 
	3.1.	 	Grant




	 	(a)	 	Subject to the provisions of this Plan, the Board may, from
time to time in its discretion, determine those Employees to whom
Options are to be granted, the number of Shares which may be
purchased pursuant to such Options, the time or times when such
Options shall vest and become exercisable, and the duration of the
exercise period.
	 
	 	(b)	 	The class of Shares which may be purchased pursuant to the
exercise of Options will be determined as set forth in Section 4.6.



 






 






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	3.2.	 	Delegation
	 
	 	 	The Board may delegate any of its responsibilities or powers under this
Plan to a committee of the Board. In such event, all references to the
Board in this Plan in respect of such responsibilities or powers shall be
deemed to be references to the committee.
	 
	3.3.	 	Limitations on Grant
	 
	 	 	The number of Shares that may be issued pursuant to Options granted under
this Plan shall not exceed 187,474 Class A Shares and 2,231,831 Class B
Shares or such greater number as shall have been approved by the
shareholders, the Board and the TSX or any other stock exchange on which
the Shares are listed.
	 
	 	 	No Option shall be granted under the Plan if such Option together with
all previously established or proposed share compensation arrangements of
the Corporation could result, at any time, in:




	 	(i)	 	the number of Shares reserved for issuance
pursuant to stock options granted to insiders exceeding 10% of
the number of Shares outstanding on a non-diluted basis
immediately prior to the time of such grant excluding Shares
issued pursuant to share compensation arrangements over the
preceding one-year period;
	 
	 	(ii)	 	the issuance to insiders within a one-year period
of a number of Shares exceeding 10% of the number of Shares
outstanding immediately prior to the time of issuance
excluding Shares issued pursuant to share compensation
arrangements over the preceding one-year period; or
	 
	 	(iii)	 	the issuance to any one insider and such
insider’s associates within a one-year period of a number of
Shares exceeding 5% of the Shares outstanding on a non-diluted
basis immediately prior to the time of issuance excluding
Shares issued pursuant to share compensation arrangements over
the preceding one-year period.




	3.4.	 	Exercise Price




	 	(a)	 	Subject to paragraph 3.4(b) and applicable rules of the TSX
or of any other stock exchange on which the Shares are listed, at
the time that it grants an Option, the Board shall fix the price per
Share payable on the exercise of the Option (the “Exercise Price”).
	 
	 	(b)	 	The Exercise Price of an Option shall not be less than the
Market Price.




	3.5.	 	No Payment on Grant
	 
	 	 	No payment to the Corporation shall be required or made on the grant of an Option.



 






 






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	3.6.	 	Option Agreement
	 
	 	 	The grant and acceptance of grant of an Option shall be evidenced by the
execution of an Option Agreement between the Corporation and the
Participant substantially in the form of Schedule A.
	 
	3.7.	 	Changes in Shares
	 
	 	 	If the Shares are subdivided, consolidated, converted or reclassified or
the number of Shares varies as a result of a stock dividend, the Board
shall adjust one or more of:




	 	(a)	 	the number or class of Shares that may be subject to Options
at any particular time;
	 
	 	(b)	 	the number or class of Shares that are subject to outstanding
Options; and
	 
	 	(c)	 	the Exercise Price of outstanding Options,




	 	 	in such manner as the Board considers appropriate in the circumstances
and all Option Agreements executed in respect of outstanding Options
shall be deemed to have been amended accordingly without any further
action or consent of the Corporation and the Employees parties to Option
Agreements.
	 
	 	 	If any Option has terminated or expired without being fully exercised,
any unissued Shares which have been reserved to be issued upon the
exercise of the Option shall become available to be issued upon the
exercise of Options subsequently granted under the Plan.
	 
	3.8.	 	Fractional Shares
	 
	 	 	No fractional shares shall be issued upon the exercise of an Option nor
shall any scrip certificates in lieu therefore be issuable at any time.
Accordingly, if as a result of any adjustment under Section 3.7, a
Participant would otherwise have become entitled to a fractional share
upon the exercise of an Option, the Participant shall have the right to
purchase only the next lower whole number of Shares and no payment or
other adjustment will be made with respect to the fractional interest so
disregarded.
	 
	3.9.	 	Designation of Subsidiary
	 
	 	 	The Board may revoke the designation of a corporation as a Subsidiary, so
long as such revocation does not have retroactive effect. For the
purposes of section 4.4, the Service Termination Date of a Participant
who is an Employee of such corporation shall be deemed to be the date of
such revocation.



 






 






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	4.	 	EXERCISE OF OPTIONS
	 
	4.1.	 	Exercise of Options
	 
	 	 	A Participant may exercise an Option, in whole or in part, at any time
after the Option vests and before its expiration.
	 
	4.2.	 	Vesting of Options
	 
	 	 	Subject to the provisions of this Plan, at the time that it grants an
Option, the Board shall fix the vesting period of such Option.
	 
	4.3.	 	Death of Participant
	 
	 	 	If a Participant dies:




	 	(a)	 	subject to paragraph (c) below, any unvested Option held by
the Participant at the time of the Participant’s death shall
immediately terminate;
	 
	 	(b)	 	any vested Option held by the Participant at the time of the
Participant’s death shall continue in effect and be exercisable as
if the Participant had remained an Employee until the earlier of (a)
the expiration date of the Option or (b) 180 days after the death of
the Participant; and
	 
	 	(c)	 	the Board may permit the exercise of an Option even though
the Option is unvested at the time of the Participant’s death for
such period of time, as may be determined by the Board, but which
shall in any event not be later than the earlier of (a) the
expiration date of the Option or (b) 180 days after the death of the
Participant.




	4.4.	 	Termination of Service
	 
	 	 	If a Participant ceases to be an Employee for any reason other than death
then:




	 	(a)	 	subject to paragraph (c) below, any unvested Option held by
the Participant at the Service Termination Date shall immediately
terminate;
	 
	 	(b)	 	any vested Option held by the Participant at the Service
Termination Date shall continue in effect and be exercisable only
for a period of 30 days after the Service Termination Date. If it
is not exercised within such 30 day period, the vested Option shall
terminate; and
	 
	 	(c)	 	the Board may permit the exercise of an Option even though
the Option is unvested at the Service Termination Date for such
period of time as may be determined by the Board but which shall in
any event not be later than the expiration date of the Option.



 






 






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	4.5.	 	Order of Exercise
	 
	 	 	A Participant may exercise Options in any order regardless of the date of
grant of the Options.
	 
	4.6.	 	Method of Exercise and Class of Shares




	 	(a)	 	A Participant or a Participant’s heirs, executors,
administrators or personal or legal representatives may exercise an
Option by delivering: (i) a written notice of exercise in the form
attached as Schedule B together with payment in full of the Exercise
Price for all Shares in respect of which the Option is being
exercised to the Secretary of the Corporation at the registered
office of the Corporation in the City of Montreal, Québec; and (ii)
a residency declaration in the form provided in Schedule C whereby
the Participant certifies whether he/she is a Canadian or a
non-Canadian.
	 
	 	(b)	 	The Option shall be deemed to have been exercised upon actual
receipt by the Secretary of the Corporation of the materials
referred to in Sections 4.6(a) and payment in full of the Exercise
Price for such Shares. A Participant who is a Canadian at the time
of exercise will be issued Class A Shares and a Participant who is a
non-Canadian at the time of exercise will be issued Class B Shares.
Upon exercise, an Option shall be cancelled.




	4.7.	 	Option Not Transferable
	 
	 	 	Subject to Section 4.8, an Option granted under this Plan shall be
transferable only by will or by the laws of intestacy and shall be
exercisable, during the lifetime of the Participant to whom the Option is
granted, only by the Participant (or, during any period in which the
Participant lacks capacity, by the Participant’s personal or legal
representatives) and, upon the death of the Participant, by the
Participant’s heirs, executors, administrators or personal or legal
representatives. No Option and none of the rights and privileges thereby
conferred shall be transferred, assigned, pledged, hypothecated in any
way or made the subject of any security of any kind whatever (whether by
operation of law or otherwise), and no Option and none of the rights and
privileges thereby conferred shall be subject to execution, attachment or
similar process. Upon any attempt by a Participant to so transfer,
assign, pledge, hypothecate, make subject to a security or otherwise
dispose of an Option or any of the rights and privileges thereby
conferred contrary to the provisions hereof, or upon the levy of any
execution, attachment or similar process upon an Option or any of the
rights and privileges thereby conferred, the Option and such rights and
privileges shall immediately terminate and cease to be exercisable.
	 
	4.8.	 	Permitted Assignments
	 
	 	 	Subject to the prior approval of the Board or, as the case may be, the
committee of the Board, a Participant may transfer Options to his or her
Family Member, (i) his or her registered retirement savings plan, which
is established for the sole benefit of the Participant, (ii) a family
trust (if he or she is a trustee and no person, other than the
Participant or a Family Member of the Participant, is a beneficiary),
(iii) a wholly-owned



 






 






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	 	 	corporation, or (iv) a corporation controlled by the Participant and all
of the minority shareholders are Family Members of the Participant,
provided, that, in any such case, the transfer is permitted by, and is
effected in accordance with the then applicable policies of the Toronto
Stock Exchange. Upon any such permitted transfer, the transferred Options
shall be deemed, for purposes of the Plan, to continue to be held by the
Participant, and shall continue to be subject to the terms and conditions
of the Plan as if the Participant remained the sole holder thereof.
	 
	5.	 	TERMINATION OF OPTION
	 
	5.1.	 	Expiration of Exercise Period
	 
	 	 	Options shall expire on the date specified in the Option Agreement or on
the date specified in Section 4.3 or 4.4 and, in any event, the term of
an Option shall not exceed 10 years from the date of grant.
	 
	5.2.	 	Bankrupt Participant
	 
	 	 	If a Participant becomes bankrupt within the meaning of the Bankruptcy
and Insolvency Act (Canada) or any other applicable bankruptcy
legislation, any unexercised Option held by such Participant shall
immediately terminate and cease to be exercisable.
	 
	6.	 	GENERAL
	 
	6.1.	 	Delivery of Shares, etc.
	 
	 	 	Any Shares to be issued to a Participant pursuant to the exercise of an
Option shall be issued not later than 30 days after the date of exercise
of the Option.
	 
	6.2.	 	Issuance of Shares
	 
	 	 	Any issue of Shares under this Plan shall be subject to applicable law
and to prior receipt of all necessary or appropriate consents, if any, of
any governmental or regulatory authorities or agencies.
	 
	6.3.	 	Administration
	 
	 	 	Subject to Section 3.2, this Plan shall be administered by the Board
which may prescribe rules and regulations respecting this Plan. The
Board has the exclusive authority to interpret and construe this Plan and
to determine all questions respecting this Plan or any Option. Any such
interpretation, construction or determination shall be final, binding and
conclusive for all purposes in respect of all persons affected thereby.
The Board may take such other actions as it considers necessary or
desirable in respect of this Plan.
	 
	6.4.	 	Incapacity
	 
	 	 	If a person to whom Shares are to be delivered or a payment made under
this Plan is a minor or is physically or mentally incapable of giving a
valid receipt, delivery or



 






 






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	 	 	payment may instead be made to a person having the legal care or custody
of the person to whom delivery or payment is to be made and any such
delivery or payment constitutes a complete discharge of the obligation to
make such delivery or payment. Any delivery or payment so made shall be
deemed to be a delivery or payment made to the person entitled to such
delivery or payment. Once such delivery or payment is made, no further
claim may be made in respect of such delivery or payment by any person
whatsoever against: (a) the Corporation, (b) any of the Corporation’s
affiliates or subsidiaries, (c) any of the Corporation’s or any of its
affiliates’ or subsidiaries’ directors, officers, employees or agents, or
(d) this Plan.
	 
	6.5.	 	Amendment and Termination
	 
	 	 	The Board may at any time by resolution amend, suspend or terminate this
Plan in any manner whatsoever, except that, subject to the provisions of
Section 6.7, no such amendment, suspension or termination shall adversely
affect the terms of any Option previously granted and not yet exercised
or expired, without the written consent of the affected Participants.
	 
	6.6.	 	Approvals
	 
	 	 	This Plan and any amendments hereto shall be subject to the approval of
the Board and any other approvals required by applicable law or the
requirements of any stock exchange upon which the Shares are listed. Any
Option granted prior to receipt of any such approval shall be conditional
upon such approval being given and no Option may be exercised until such
approval is given. Notwithstanding any other term of this Plan, the
Corporation is not obliged to take any action or to refrain from taking
any action if such action (or refraining therefrom) would result in a
breach of any applicable law, regulation, judgment, directive, rule,
consent, approval, authorization, guideline, order or policy of any
governmental or other regulatory authority (including any stock exchange
upon which the Shares are listed).
	 
	6.7.	 	Reorganization
	 
	 	 	In the event of a Change in Control, a reorganization of the Corporation,
an amalgamation of the Corporation, an arrangement involving the
Corporation, a take-over bid (as that term is defined in the Securities
Act (Québec)) for all of the Shares or the sale or disposition of all or
substantially all of the property and assets of the Corporation, the
Board may make such provision for the protection of the rights of the
Participants as the Board in its discretion considers appropriate in the
circumstances, including changing the date on which any Option vests
and/or the date on which any Option expires.



 






 






SCHEDULE A



Form of Option Agreement



This option agreement is entered into between Microcell Telecommunications Inc.
(the “Corporation”) and the Participant named below pursuant to the Stock
Option Plan of the Corporation (the “Plan”).


This agreement evidences that
on               the
Participant has been granted an Option to
purchase               Shares
at an Exercise Price of
$               per Share.


The Option vests in the Participant and, subject to early expiry in the event
of death or termination of service, expires as follows:



	 	 	 	 	 	 	 	 	 
	Number of Shares	 	Vesting Date	 	Expiry Date
	
	 	
	 	

	 
 
 
 
 




The Option is subject to the terms of the Plan. Capitalized terms used but not
defined in this certificate have the meanings given to them in the Plan.


This agreement and all related documents have been drawn up in the English
language at the specific request of the parties hereto. Ce contrat et tous les
documents relatifs ont été rédigés dans la langue anglaise à la demande
expresse des parties aux présentes.


     And the
parties have signed as
of               .



	 	 	 	 	 
	 	MICROCELL TELECOMMUNICATIONS INC.
	 	 	 	 	 
	 	
By:	 	 
	 	 	

	 	 
	 	 	
Name:	 	 
	 	 	
Title:	 	 
	 	 	 	 	 
	 	
Acknowledged and accepted by:	 	 
	 	 	 	 	 
	 	

	 	 
	 	
Name of Participant	 	 



 






 



SCHEDULE B



Notice



TO:                Secretary of Microcell Telecommunications Inc.


I refer to the Option to
purchase               Shares at an
Exercise Price of $               per Share (the “Exercise Price”) pursuant to the
Stock Option Plan of Microcell Telecommunications Inc. (the “Plan”) that was
granted to me on               and is evidenced by a Stock option
agreement executed as of               .


Capitalized terms used but not defined in this notice have the meanings given
to them in the Plan.


I hereby exercise the Option in respect of               Shares
(the “Exercised Shares”) thereby subscribing for the Exercised
Shares at a subscription price per Exercised Share equal to the Exercise Price
for an aggregate subscription price of $               (the “Subscription
Price”).


Please register               Exercised Shares in
my name and forward the share certificate evidencing such Exercised Shares to
me at the address noted below. A cheque in the amount of
$               
on account of the Subscription Price is attached to this notice.



	 	 	 
	
	 	

	Address of Participant (PLEASE PRINT)	 	
Name of Participant (PLEASE PRINT)
	 	 	 
	
	 	

	 	 	
Signature of Participant
	 	 	 
	
	 	

	 	 	
Date



 






 



SCHEDULE C



FORM OF RESIDENCY DECLARATION



TO:                Microcell Telecommunications Inc.


In connection with the Stock Option Plan of Microcell Telecommunications Inc.,
the undersigned, being the person in whose name shares in the capital of
Microcell Telecommunications Inc. (the “Shares”) are to be registered, hereby
DECLARES and REPRESENTS that:


o  the undersigned is Canadian as defined herein, OR


o  if other than the undersigned is not Canadian as defined herein.


For purposes of this residency declaration “Canadian” means:



	(a)	 	a citizen within the meaning of subsection 2(1) of the Citizenship Act
(Canada) who is ordinarily resident in Canada; or
	 
	(b)	 	a permanent resident within the meaning of subsection 2(1) of the
Immigration Act (Canada) who is ordinarily resident in Canada, and has
been ordinarily resident in Canada for not more than one year after the
date on which that person first became eligible to apply for Canadian
citizenship.



DATED
the               day of
20               .





Name:

Address: