Government of Ontario: Ministry of Children, Community and Social Services

Application for a Licence or Renewal of a Licence to Place Children for Adoption

To: A Director appointed for purposes of the Child, Youth and Family Services Act, 2017 (“the Act”)

Under the Act and regulations thereunder, I
hereby apply for,

a Licence or Renewal of Licence to place children up for adoption.

Complete A or B

A. if unincorporated Operator

Applicant/Operator

Ms. Miss Mrs. Mr.
Last Name (Surname)
First Name (Given Name)
Middle Initial
Occupation
Telephone No. (incl. area code)
Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code

B. If Corporation will operate:

Corporation Name
Telephone No. (incl. area code)

Head office address

Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code

Present members of Board of Directors

(attach additional pages if required)
1. Last Name
1. First Name
1. Middle Initial
1. Occupation
1. Office held
1. Unit No.
1. Street No.
1. Street Name
1. PO Box
1. City/Town
1. Province
1. Postal Code

2. Last Name
2. First Name
2. Middle Initial
2. Occupation
2. Office held
2. Unit No.
2. Street No.
2. Street Name
2. PO Box
2. City/Town
2. Province
2. Postal Code

Present Officers of Corporation

(not included above, attach additional pages if required )
1. Last Name
1. First Name
1. Middle Initial
1. Occupation
1. Office held
1. Unit No.
1. Street No.
1. Street Name
1. PO Box
1. City/Town
1. Province
1. Postal Code

2. Last Name
2. First Name
2. Middle Initial
2. Occupation
2. Office held
2. Unit No.
2. Street No.
2. Street Name
2. PO Box
2. City/Town
2. Province
2. Postal Code

Name of Agency
Agency Telephone No. (incl. area code)

Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code

Name of Program Director

Last Name
First Name
Middle Initial

Qualification of Program Director (attach curriculum vitae)

A certified copy of the Letters Patent of the applicant corporation is attached to this Application as Schedule A.

The proposal for staffing is as follows: (indicate classifications, qualifications and work experience and number of persons in each classification).

List staff already hired: (give names and classifications)

1. Last Name
1. First Name
1. Middle Initial
1. Classifications

2. Last Name
2. First Name
2. Middle Initial
2. Classifications

3. Last Name
3. First Name
3. Middle Initial
3. Classifications

List access to professional services required and basis of access, e.g., fee for service, employee, etc. (give names of professionals, addresses, credentials)

Application is being made for a special term under subsection 183 (2) of the Act.
Application is being made for exemption under subsection 183 (6) of the Act.
Other terms or conditions are being requested (attached).
Appropriate supporting documentation is attached.

The applicant hereby agrees to comply with the
provisions of the Child, Youth and Family Services Act, 2017
and the regulations thereunder.

Dated at , this Day day of Month Year

Signature of applicant or authorized officers of corporation

I hereby certify that:

I am a member of the Board of Directors of
Name of Corporation
I have knowledge of the matter and the statements in the annexed application are contained are, to the best of my knowledge and belief, true in substance and in fact.
Each of the members of the Board of Directors is eighteen or more years of age and each member’s name and description have been accurately set out in the application.
The application is made in good faith and is not made for any improper purpose.

Dated this Day day of Month Year

Signature of witness or affix corporate seal

Signature of applicant

Information on this form is collected under the legal authority of the Child, Youth and Family Services Act, 2017 for the purpose of administering Ministry of Children, Community and Social Services programs and/or services. For more information contact: Director, Client Services Branch, Ministry of Children, Community and Social Services, 6^th Fl., 101 Bloor St. W., Toronto ON M5S 2Z7 or call 416-326-3170.