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Application for Post Adoption Birth Information Under ...

11315E (2010/05) Queen s Printer for Ontario, 2010 Page 1 of 3 Disponible en fran aisApplication for post Adoption Birth Information Under section or of the Vital Statistics ActService Requested: Disclosure of Adoption related Information Under section or of the Vital Statistics Act. (THIS SPACE RESERVED FOR OFFICE USE ONLY)Please mail your completed form to ServiceOntario Offi ce of the Registrar GeneralPO Box 9000 Thunder Bay ON P7B 0A5If you have any questions, please callWithin North America: 1 800 461-2156In Toronto or Internationally: 416 325-8305 Important Please read through the instructions thoroughly before completing this print clearly in blue or black Legal Surname (Last Name)First and Middle NamesSection A - Applicant InformationStreet NamePO BoxCity/TownProvince/StateBuzzer Address at which correspondence from this offi ce regarding this Application can be mailed to you: CountryPostal/Zip Code Apt.

11315E (2010/05) Page 3 of 3 Application for Post Adoption Birth Information Under Section 48.1 or 48.2 of the Vital Statistics Act On conviction, a person who willfully makes a false statement in this application is liable to a fi ne of not more than $50,000 or to

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