Social Insurance Number Application
Download a blank fillable Social Insurance Number Application in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Social Insurance Number Application with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Government
Gouvernement
of Canada
du Canada
PROTECTED WHEN COMPLETED - A
SOCIAL INSURANCE NUMBER APPLICATION
DATE
FINDER NO
APPLICATION FOR A
DO NOT WRITE IN THIS AREA
FIRST SOCIAL INSURANCE NUMBER CARD
REPLACEMENT CARD
LEGAL CHANGE OF NAME(S)
CHANGE OF STATUS
UPDATE TO RECORD (no card will be issued)
CHANGE TO THE EXPIRY DATE
OTHER - SPECIFY
INFORMATION CONCERNING THE APPLICANT
PRINT CLEARLY IN BLUE OR BLACK INK
First Given Name
Other Given Names (to be printed on card)
Family Name
NAME TO BE
SHOWN ON
1
CARD
Day
Month
Year
Male
DATE OF
2
3
GENDER
Check if you are a twin, triplet, etc.
BIRTH
Female
MOTHER'S
Given Name(s)
FATHER'S
Given Name(s)
Family Name
Family Name
NAME
NAME
4
5
(at birth)
City, Town or Village
Province
Country
APPLICANT'S
PLACE OF
6
BIRTH
APPLICANT'S FAMILY NAME AT BIRTH
OTHER FAMILY NAME(S) PREVIOUSLY USED
7
8
HAVE YOU EVER HAD
IF "YES", WRITE YOUR
9
10
A SOCIAL INSURANCE
No
Yes
NUMBER HERE
NUMBER?
Check one of the following:
Home Telephone Number
Daytime Telephone Number
STATUS IN
Permanent
Registered
CANADA
Canadian
Other
11
12
Resident
Indian
Citizen
(
)
(
)
Yes
No
Are you currently residing in Canada?
In care of (if different than item 1)
MAIL TO
(Address where you
want your card to be
Number and Street
Apartment No.
13
sent)
Province
City, Town or Village
Postal Code
If the applicant is under 12 years of age, the father, mother or legal guardian must sign and indicate his/her relationship. If you are a
14
guardian, you must submit a document showing proof of legal guardianship. If "X" is used as a signature, have two witnesses sign here.
Date
APPLICANT'S SIGNATURE
The name(s) formerly used will be maintained in the Social Insurance Number register. Information collected on this form is used for the purpose of issuing Social Insurance
Numbers. Its collection is authorized by the Employment Insurance Act. For more details on the uses and rights concerning inspection and correction of the information, refer to
the publication Info Source, Bank No. HRDC PPU 390, available in Human Resource Centres of Canada and major public libraries.
IT IS AN OFFENCE TO KNOWINGLY APPLY FOR MORE THAN ONE SOCIAL INSURANCE NUMBER AND TO GIVE OR LEND YOUR CARD TO ANYONE.
DO NOT WRITE BELOW - FOR LOCAL OFFICE USE ONLY
Given Names
Family Name
ALL NAMES
A
AS SHOWN
ON PRIMARY DOC.
Day
Month
Year
Abbreviation
DATE OF BIRTH
PRIMARY
B
C
D
AS SHOWN
DOCUMENT
NUMBER ON
ON PRIMARY DOC.
SEEN
DOCUMENT
Abbreviation
SUPPORTING
CERTIFICATION STAMP
LOCAL OFFICE
E
F
DOCUMENT SEEN
FAX NO.
G
FEE PAID
$
Amount
Receipt No.
REMARKS / REASON FOR PRIORITY REQUEST
H
Usercode
NAS-2120-(05-04)
(Internet version)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal