BRI _____________ CID _____________
If you have any questions, please contact: ServiceOntario Toll-free: 1 800 461-2156 or Toronto: 416 325-8305
Important:
Mr. Mrs. Ms. Miss. Current Legal Surname (Last Name) First Name Middle Name(s) Maiden Name or Other Surname(s) (if applicable)
Male Female
Date of Birth (dd/mm/yyyy)
Street No. Street Name Apt. No. Buzzer No. PO Box City/Town Province/State Country Postal/Zip Code
( Enter area code ) Enter telephone number Ext.
Yes No
Adoptive Surname (Last Name) of Adopted Person First Name Middle Name(s)
Date of Adoption (if known)
If "Yes" provide details below
Current Legal Surname (Last Name) First Name Middle Name(s)
City/Town Province/State Country
Legal Surname (Last Name) of Adoptive Parent "A" (at time of adoption) First Name Middle Name(s) Any Other Possible Surnames (Last Name)
Legal Surname (Last Name) of Adoptive Parent "B" (at time of adoption) First Name Middle Name(s) Any Other Possible Surnames (Last Name)
Surname (Last Name) of Adopted Person (at time of birth) First Name Middle Name(s)
Birth Registration Number (if known)
Legal Surname (Last Name) of Birth Mother (at time of birth) First Name Middle Name(s) Any Other Legal Surnames (Last Name)
Legal Surname (Last Name) of Birth Father (at time of birth) First Name Middle Name(s) Any Other Legal Surnames (Last Name)
I hereby certify that the information I have provided on this application form is true and correct to the best of my knowledge and belief.
(Signature of Applicant)
(Date of Signature)
Mail your completed application to: Custodian of Adoption Information P.O. Box 654 77 Wellesley St. West Toronto ON M7A 1N3
The information provided on this form is collected and will be used to determine your entitlement to receive a copy of an Adoption Order with any information that may reveal the identity of a birth parent removed section 21.1 of O.Reg. 464/07 made under the Child and Family Services Act. If you have any questions about the collection of information, please contact: Director, ServiceOntario Call Centre, Contact Centre Service Branch, 5775 Yonge St, Toronto, Ontario M3M 3E6 or call 1 800 461-2156 / 416 325-8305.
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