BRI _____________ CID _____________
If you have any questions, please contact: Service Ontario Toll-free: 1 800 461-2156 or Toronto: 416 325-8305
Important: Please read through the instructions thoroughly before completing this form. Please print clearly in blue or black ink.
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
An adopted person 18 years of age or older A birth sibling of an adopted person, and you are 18 years of age or older
Birth Mother Birth Father Maternal grandmother Maternal grandfather Paternal grandmother Paternal grandfather
Birth Sibling Birth Mother Birth Father Maternal grandmother Maternal grandfather Paternal grandmother Paternal grandfather
Important: The information you provide in this section will be entered on the Adoption Disclosure Register and will be given to the adopted person or the adopted person's birth parent, birth sibling, or birth grandparent in the event that a register match is confirmed.
Please indicate how you wish to be contacted by the adopted person or the birth parent, birth sibling or birth grandparent in the event a register match is confirmed, by checking the boxes below and filling out those sections that apply to you. (You may check more than one box)
Enter area code Enter fax number
E-mail Address
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 Legal Surnames (Last Name)
Legal Surname (Last Name) of Adoptive Parent "B" (at time of adoption) First Name Middle Name(s) Any Other Legal 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 provide my consent to be named on the Adoption Disclosure Register under section 7 of O.Reg. 464/07 made under the Child and Family Services Act, and 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 PO Box 654 77 Wellesley St. West Toronto ON M7A 1N3
The information provided on this form is collected and will be used to determine whether your name may be added to the Adoption Disclosure Register and whether your name can be matched to that of an adopted person, birth parent, birth sibling or birth grandparent by the purpose of disclosure by the MCSS Custodian of Adoption Information under section 9 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 ON M3M 3E6 or call 1 800 461-2156 / 416 325-8305.
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