Sc Isp-3210 - Canadian Citizenship Application Form Page 3
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12. List all names you have ever used.
Other name(s)
Date of Birth
Surname (Family Name)
Given name(s)
(Middle name, maiden
name, alias, initials, etc.)
YYYY-MM-DD
PART C - IF YOU ENTERED CANADA AS A PERMANENT RESIDENT PRIOR TO 1973, COMPLETE THE
FOLLOWING SECTION
(If you are completing this section, please note that all fields are mandatory. If you
do not have the information requested, please state “unknown” in the space provided.)
1. Provide the full names and date of birth of the person(s) who accompanied you on arrival in Canada.
(e.g., middle name, maiden name, English name or alias.)
Other name(s)
Date of Birth
Surname (Family Name)
Given name(s)
(Middle name, maiden
name, alias, initials, etc.)
YYYY-MM-DD
2. Were either of your parents born Canadian Citizens?
Yes
No
3. What are the names and dates of birth of your parents?
Other name(s)
Date of Birth
Surname (Family Name)
Given name(s)
(Middle name, maiden
name, alias, initials, etc.)
YYYY-MM-DD
PART D - PROVISION OF CONSENT
I acknowledge I have read and understand the contents of this form. I hereby provide my consent allowing
Service Canada to collect the above information, provide it to Citizenship and Immigration Canada (CIC), and
obtain information from CIC that will be used to determine my eligibility and entitlement to an OAS pension
and/or benefits and administer the OAS Program. My consent also allows CIC to use and disclose the
information for the purposes of the administration and enforcement of the Immigration and Refugee Protection
Act and the Citizenship Act.
Date of Signature (YYYY-MM-DD)
Signature
SC ISP-3210 (2015-07-21) E
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