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Form Cit 0001 - Application For A Citizenship Certificate For Adults And Minors - Immigration, Refugees And Citizenship Canada Page 2

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For official use only

UCI no.

Application for

Case ID

a Citizenship Certificate

Current Act

Former Act

for Adults and Minors

(Proof of Citizenship)

Certificate no.

Under Section 3

Return original

Approved

document(s)

Note:

If you are completing this application for

Signature

a child under 18 years of age, remember

all questions are about the child.

YYYY-MM-DD

Notify:

Send certificate to:

Please PRINT in ink or TYPE

PROTECTED WHEN COMPLETED

I want service in

Please check

one

English

French

Have you ever had a certificate of Canadian citizenship or naturalization?

Yes

If yes, give information that appears on the certificate.

Surname/Last name

Given name(s)

Certificate number

Date (YYYY-MM-DD)

a) to update certificate

I am applying for a replacement:

(previous certificate enclosed)

b) to replace a

stolen

lost

destroyed

certificate.

Yes

Was the theft/loss reported to the police?

Please give details of the theft/loss/destruction (when, where, how and what?)

Note:

It is illegal to have more than one valid certificate of citizenship or naturalization. If you have any certificate of citizenship and

naturalization or any pink transmission copy of a certificate, you have to send it back. If you find a certificate that was

declared stolen, lost or destroyed after you get your replacement certificate, you have to send it back to the Case Processing

Centre in Sydney, Nova Scotia.

A Name (exactly as it is shown on

Last name (Surname/Family name)

Given name(s)

my birth certificate or previous

certificate)

B Request for a different name to

Last name (Surname/Family name)

Given name(s)

appear on certificate (subject to

approval by Immigration,

Refugees and Citizenship Canada)

Last name (Surname/Family name)

C List any other names (include birth name,

maiden, previous married name(s), aliases

Given name(s)

and nicknames). These names will not

appear on your citizenship certificate

A Birth details as shown on my birth

YYYY - MM - DD

I am requesting a date of birth change?

Yes

certificate or previous certificate

B Place and country of birth

Colour

C Personal information

Sex

Male

OR Female

Height

of eyes

Marital status

Single

Married

Common-law

Widowed

Divorced

Separated

This form is made available by Immigration, Refugees and Citizenship Canada and is not to be sold to applicants.

CIT 0001 (04-2016) E

(DISPONIBLE EN FRANÇAIS - CIT 0001 F)

Form Cit 0001 - Application For A Citizenship Certificate For Adults And Minors - Immigration, Refugees And Citizenship Canada Page 2

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