Application For Change Of Name Of An Adult - Vital Statistics Division
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1
2Application for
Change of Name of an Adult
To be completed by the person applying to change their own name
Applicant Information
1
Surname Only
Given Names Only
Both Surname and Given Name
Intent of
Change
NOTE: A change of name will be reflected on the Registration of Birth if the event occurred in Newfoundland and Labrador (and within Canada in most
cases). However, a change of name will only be reflected on the Registration of Marriage if requested and with the consent of the other spouse.
Current Name
Surname
Given Name
Middle Name(s)
Female
(as shown on birth
registration)
Male
Surname
Given Name
Middle Name(s)
Proposed Name
City / Town
Province / State
Country
Y Y Y Y
M M
D D
Date and
Place of Birth
Street
Current Address
City / Town
Province / State
Postal Code
Country
Documentation
2
Original Birth Certificate
Birth Registration Number
(if born in Canada)
Enclosed
Request for Birth Certificate attached
(if born in NL and do not have a birth certificate)
Proof of
Birth
Certified copy of Immigration and Citizenship Documents (if born outside Canada)
Enclosed
Publication of Change of Surname
3
I understand that by making application for a change of surname for myself, a notice of the change of surname will be published in
the Gazette.
AFFIDAVIT OF GOOD FAITH
Applicant’s
Statutory
I, ______________________________________________________________________________________________________________
Declaration
of ______________________________________________________________________________________________________________
in the Province of Newfoundland and Labrador, DO SOLEMNLY SWEAR / AFFIRM:
1. That I am the applicant named in the above application which I make in good faith without intention to defraud, mislead or
conceal my previous identity for an improper purpose.
2. That I have been ordinarily resident in the Province of Newfoundland and Labrador for at least three (3) months.
3. That I am aware that notice of my change of name may be provided to peace officers, as well as other public officers of
departments and agencies of Government.
4. That I have read the application for a change of name and, to the best of my knowledge, information, and belief, the
statements made therein are true in substance and in fact.
AND I MAKE THIS SOLEMN DECLARATION conscientiously believing it to be true, and knowing that it is of the same force and
effect as if made under oath and by virtue of the Canada Evidence Act.
SWORN TO / AFFIRMED before me
Signature of Applicant
at ________________________________________________
in the _________________ of _________________________
this _____ day of __________________________, 20_____.
Commissioner of Oaths / Justice of the Peace /
Notary Public - with raised seal
(if completed outside Newfoundland and Labrador)
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