Nas2120b - Application For A Social Insurance Number Card
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1
2Human Resources
Développement des
PROTECTED WHEN COMPLETED - A
Development Canada
ressources humaines Canada
APPLICATION FOR A:
FINDER NO:
DO NOT WRITE IN THIS AREA
If you are replacing your SIN card,
you must pay a $ 10.00 fee
FIRST SOCIAL INSURANCE NUMBER CARD (fee not required)
REPLACEMENT CARD (fee required)
CHANGE OF NAME(S) ON CARD (fee not required)
CHANGE OF STATUS (fee not required)
YOUR APPLICATION WILL BE RETURNED IF NOT ACCOMPANIED
OTHER CHANGES (no card will be issued and no fee required)
BY THE REQUIRED DOCUMENTS
INFORMATION CONCERNING THE APPLICANT. PLEASE PRINT CLEARLY.
First Name
Middle Name (if wanted on card)
Family Name
NAME TO BE
1
SHOWN ON
CARD
Day
Month
Year
Male
DATE OF
2
3
SEX
Check block if you are a twin
BIRTH
Female
MOTHER'S FULL NAME AT HER BIRTH
FATHER'S FULL NAME AT HIS BIRTH
4
5
City, Town or Village
Province
Country
APPLICANT'S
6
PLACE OF
BIRTH
FAMILY NAME AT BIRTH
OTHER FAMILY NAME(S) PREVIOUSLY USED
7
8
HAVE YOU EVER HAD
IF "YES", WRITE YOUR
9
10
No
Yes
A SOCIAL INSURANCE
NUMBER HERE
NUMBER?
(
)
Home
Telephone
Canadian
STATUS IN
Registered
Permanent
11
12
Other
Citizen
Indian
Resident
Numbers
CANADA
(
)
Work
Number and Street
Apartment No.
ADDRESS WHERE
YOU WANT YOUR
13
SIN CARD TO BE
City, Town or Village
Province
Postal Code
MAILED
(If you are under 12 years of age, your parent / guardian must sign and indicate his / her relationship.
If "X" is used as a signature, have two witnesses sign here).
14
Date
Applicant's Signature
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 LIBRAIRIES.
IT IS AN OFFENCE TO KNOWINGLY APPLY FOR MORE THAN ONE SOCIAL INSURANCE NUMBER.
YOU ARE NOT PERMITTED 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
(Abbr.)
(Abbr.)
(Client ID - Serial / Reg. No.)
DATE OF BIRTH
PRIMARY
SUPPORTING
B
C
AS SHOWN
DOCUMENT
DOCUMENT
ON PRIMARY DOC.
SEEN
SEEN
ELECTRONIC MAIL ADDRESS
PRIORITY SIN REASON
D
CERTIFICATION STAMP
E
FEE PAID
$
Amount
Receipt No.
REMARKS
F
NAS 2120 (02-02) B
(Internet version of the application, 2002.05.17)
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