3
4
Birth details as shown on my birth certificate or
previous certificate
Date
destroyed
Note:
1
Please check (9) one
(AUSSI DISPONIBLE EN FRANÇAIS - CIT 0001 F)
AVAILABLE ON CIC WEB SITE AT: http://www.cic.gc.ca
Name (exactly as it is shown on
my birth certificate or previous
certificate)
2
I want service in
cm
Sex
For official use only
Application for
a Citizenship Certificate
(Proof of Citizenship)
Under Section 3
CIT 0001 (04-2009) E
PAGE 1 OF 5
Protected when completed
Please PRINT in ink or TYPE
English
French
List any other names (include birth name,
maiden, previous married name(s), aliases and
nicknames). These names will not appear on
your citizenship certificate
Have you ever had a certificate of Canadian citizenship or naturalization?
If yes, give information that appears on the certificate.
No
Yes
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
lost certificate after you get your replacement certificate, you have to send it back to the Case Processing Centre
in Sydney, Nova Scotia.
Place and country of birth
Personal information
OR Female
Height
OR
ft in
Colour
of eyes
Male
If you are completing this application for
a child under 18 years of age, remember
all questions are about the child.
Citizenship and
Immigration Canada
Citoyenneté et
Immigration Canada
Surname/Last name
Given name(s)
Certificate number
Day
Month
Year
Was the theft/loss reported to the police?
Please give details of the theft/loss/destruction (when, where, how and what?)
No
I am applying for a replacement:
a) to update certificate
(previous certificate enclosed)
lost
Yes
certificate.
b) to replace a:
stolen
A
B
C
Signature
UCI no.
Case ID
Current Act
Certificate no.
Return original
document(s)
Former Act
Approved
Notify:
Send certificate to:
Marital status Single
Married
Widowed
Divorced
Separated
Common-
law
M
D
Y
A
B