Ontario Birth Certificate Application Page 2
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3Application - continued
Where Birth Occurred:
Hospital: __________________________________________
Home
Birthing Centre
Name
Other:
__________________________________________
Please Specify
Who Delivered Subject:
Physician
Midwife
Other
Unknown
Name of Doctor/Attendant
: _______________________________________________________________________
(at time of subject’s birth)
Address of Doctor/Attendant: _______________________________________________________________________________________
Mother’s Name: _______________________________
_______________________________
_______________________________
First
Middle
Last (Maiden name)
Other Last Name(s) Used by Mother: _________________________________________________________________________________
Mother’s Address: _______________________________________________________ Apt.: ___________ Buzzer Code: ___________
Address at time of subject’s birth
City: _________________________ Prov./State: _________________ Country: _________________ Postal/Zip Code: _______________
Mother’s Marital Status
:
Single
Married
Divorced
Widowed
Common Law
(at time of subject’s birth)
:
Mother’s Age
: __________
Mother’s Date of Birth
_______________
___________
___________
(at time of subject’s birth)
Month
Day
Year
Mother’s Place of Birth:
City/Town: _________________________ Prov./State: _________________ Country: ________________
Father’s Name: _______________________________
_______________________________
_______________________________
First
Middle
Last
:
Father’s Age
: __________
Father’s Date of Birth
_______________
___________
___________
(at time of subject’s birth)
Month
Day
Year
Father’s Place of Birth:
City/Town: _________________________ Prov./State: _________________ Country: ________________
Guarantor -
This section must be completed for subjects aged 9 or older.
Guarantors must be known by the applicant (name shown on Contact Information) for at least two years, reside in Canada, be a Canadian
citizen, hold an occupation from the list below, is not retired, and is a practicing member in good standing. You must have permission by
the guarantor to provide his or her information. The guarantor can be a family member, provided they hold an occupation from the list
below. The guarantor does not need to sign the application.
The following are guarantors for the purposes of section 45.1 of the Vital Statistics Act: Chief of a band recognized under the Indian
Act (Canada), chiropractor, dentist, First Nations police officer, judge, justice of the peace, lawyer, mayor, member of the Legislative
Assembly of Ontario (MPP), midwife, minister of religion authorized under provincial law to perform marriages, municipal clerk or
treasurer (a member of the Association of Municipal Managers, Clerks and Treasurers of Ontario), notary public, nurse, optometrist,
pharmacist, physician, police officer (municipal, provincial, RCMP), principal or vice-principal (primary or secondary school), professional
accountant, professional engineer, psychologist, senior administrator (community college or in a CEGEP), senior administrator or professor
in a university, signing officer of a bank, caisse d'économie, caisse populaire, credit union or trust company social worker or social service
worker, surgeon, teacher in a primary or secondary school or Veterinarian.
Name: ____________________________
____________________________
Occupation: ________________________________
First
Last
Must be an occupation listed above
Organization/Firm (if applicable): ______________________________________
Registration #: ______________________________
If available or applicable
Work Address: _____________________________________________________
Unit/Suite: _______ City: _____________________
Province: __________________________
Postal Code: ___________________
Daytime Phone Number: (______) _____________________ Extension:
_______e
Fax Number: (______) _______________________
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