Fillable Printable Social Insurance Number Application Form - Canada
Fillable Printable Social Insurance Number Application Form - Canada
Social Insurance Number Application Form - Canada
Government
of Canada
Gouvernement
du Canada
PROTECTED WHEN COMPLETED - A
SOCIAL INSURANCE NUMBER APPLICATION
APPLICATION FOR A
FINDER NO DATE
DO NOT WRITE IN THIS AREA
INFORMATION CONCERNING THE APPLICANT PRINT CLEARLY IN BLUE OR BLACK INK
1
NAME TO BE
SHOWN ON
CARD
First Given Name
Other Given Names (to be printed on card)
Family Name
2
DATE OF
BIRTH
Day Month Year
3
GENDER
4
MOTHER'S
NAME
(at birth)
Given Name(s)
Family Name
5
FATHER'S
NAME
Given Name(s) Family Name
6
APPLICANT'S
PLACE OF
BIRTH
City, Town or Village Province Country
7
APPLICANT'S FAMILY NAME AT BIRTH
8
OTHER FAMILY NAME(S) PREVIOUSLY USED
9
HAVE YOU EVER HAD A
SOCIAL INSURANCE
NUMBER?
10
IF "YES", WRITE YOUR
NUMBER HERE
11
STATUS IN
CANADA
Check one of the following:
Are you currently residing in Canada? Yes No
12
Home Telephone Number Daytime Telephone Number
13
MAIL TO
(Address where you
want your card to be
sent)
In care of (if different than item 1)
Number and Street Apartment No.
City, Town or Village Province Postal Code
14
If the applicant is under 12 years of age, the father, mother or legal guardian must sign and indicate his/her relationship. If you are a
guardian, you must submit a document showing proof of legal guardianship. If "X" is used as a signature, have two witnesses sign here.
APPLICANT'S SIGNATURE
Date
The name(s) formerly used will be maintained in the Social Insurance Number register. 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 libraries.
IT IS AN OFFENCE TO KNOWINGLY APPLY FOR MORE THAN ONE SOCIAL INSURANCE NUMBER AND TO GIVE OR LEND YOUR CARD TO ANYONE.
DO NOT WRITE BELOW - FOR LOCAL OFFICE USE ONLY
ALL NAMES
AS SHOWN
ON PRIMARY DOC.
Given Names
Family Name
DATE OF BIRTH
AS SHOWN
ON PRIMARY DOC.
Day Month Year
C
PRIMARY
DOCUMENT
SEEN
Abbreviation
D
NUMBER ON
DOCUMENT
E
SUPPORTING
DOCUMENT SEEN
Abbreviation
F
LOCAL OFFICE
FAX NO.
G
FEE PAID
Amount $ Receipt No.
H
REMARKS / REASON FOR PRIORITY REQUEST
CERTIFICATION STAMP
Usercode
NAS-2120-(05-04)
(Internet version)
FIRST SOCIAL INSURANCE NUMBER CARD
REPLACEMENT CARD
LEGAL CHANGE OF NAME(S)
CHANGE OF STATUS
UPDATE TO RECORD (no card will be issued)
CHANGE TO THE EXPIRY DATE
OTHER - SPECIFY
Male
Female
Check if you are a twin, triplet, etc.
YesNo
Canadian
Citizen
Registered
Indian
Permanent
Resident
Other
B
A
INSTRUCTION SHEET
A -
Complete the application form.
B -
You must provide an original primary document according to your status in Canada. Refer to leaflet "Documents you need to apply for a Social
Insurance Number (SIN) " (IN-105).
C -
If the name on your primary document is different from the name you are now using, you must also submit an original supporting document. Refer
to leaflet "Documents you need to apply for a Social Insurance Number (SIN)" (IN-105).
D -
If you are replacing your SIN card, you must pay a $10.00 fee (subject to change). Make your personal cheque, bank draft or money order
payable in Canadian funds to the RECEIVER GENERAL FOR CANADA. You may pay in cash at a Human Resource Centre of Canada. DO NOT
MAIL CASH.
E -
If you are a guardian, you must submit an original document showing proof of legal guardianship in order to sign an application form on behalf of
the applicant.
The information contained in the vital statistics registers and the Citizenship and Immigration Canada records can be used to validate information
that you provide with this application form when presenting a document orginating from these sources.
If you are employed, it is important that the name and Social Insurance Number under which you are working are identical to the name
and Social Insurance Number that appear on your card. This will ensure that your Canada Pension Plan and/or Quebec Pension Plan
contributions are properly credited to you.
TO APPLY IN PERSON
We encourage you to take your application and original document(s) to the nearest Human Resource Centre of Canada. Your application will be
certified and your document(s) will be returned to you immediately.
TO APPLY BY MAIL
If it is not convenient for you to apply in person, you may mail your application and original document(s) required, and fee if applicable, to the address
below. Your document(s) will be returned with your card. PLEASE NOTE THAT WE ARE NOT ACCOUNTABLE FOR DOCUMENTS LOST IN
TRANSIT.
Social Insurance Registration
P.O. Box 7000
BATHURST NB E2A 4T1
If your application is in order, you should receive your Social Insurance
Number card in approximately three weeks. If you do not receive your SIN
card within this period, please call 1 800 206-7218.
FOR MORE INFORMATION
Visit the Social Development Canada Web site at www.sdc.gc.ca or dial toll-free 1 800 206-7218.
For general enquiries, you can also contact us by e-mail at [email protected] .
DETACH HERE DETACH HERE
DO NOT WRITE BELOW - FOR LOCAL OFFICE USE ONLY
PROTECTED WHEN COMPLETED - A
ACKNOWLEDGMENT OF APPLICATION
FOR A SOCIAL INSURANCE NUMBER
The Employment Insurance Act requires a person to apply for a Social Insurance Number and to produce his/her Social Insurance Number card to
his/her employer within three (3) days after having received it. However, the legislation does not prevent persons from working in insurable
employment prior to being issued a Social Insurance Number and card.
Accordingly, this acknowledges that
has applied for a first Social Insurance Number.
has applied for a replacement card.
has applied to change the expiry date.
Social Insurance Number
When the application is approved, the Social Insurance Number card will be sent to the
address specified by the applicant at the time of application.
HRCC STAMP
(DO NOT use SIN Certification Stamp)
Initials Date
NAS-2120-(05-04)
(Internet version)
Government
of Canada
Gouvernement
du Canada
Government
of Canada
Gouvernement
du Canada
