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A. Personal Information |
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Last Name
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First Name
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Middle Name
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Sex
Male Female
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Date of Birth (year/month/day)
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Language Preference
English French
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Have you ever had on Ontario Health Number?
Yes No
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If Yes, what number?
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Home Telephone No.
( )
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No phone
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Work or other telephone no
( )
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Have you recently left the Canadian Forces, RCMP, or a
federal penitentiary? Yes No |
If yes, were you discharged? (y/m/d)
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B. Mailing Address |
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Street no. and name, P.O. box no., R. R., General Delivery
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Apartment no.
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City
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Province
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Postal Code
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Country
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C. Residence address if different from mailing address |
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Street no. and name, lot, concession, township
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Apartment
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City
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Province
ON
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Postal Code
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D. Residence in Ontario |
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Have you lived in Ontario since birth? Yes No
If No, complete this section. If Yes, go to section E.
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How long do you plan to live in Ontario? Permanently p
Until |
Are you a student? Yes No |
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Where did you move from?
(Student number and name)
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Apartment
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City
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Province
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Country
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When did you move to Ontario? (y/m/d)
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When did you leave the above address? (y/m/d)
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Former telephone no.
(
)
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If you moved from another part of Canada, were you covered by a
government health plan? Yes No |
If Yes, what was your health number?
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Are you a Canadian Citizen returning to Canada? Yes
No |
Are you an immigrant returning to Canada? Yes
No |
Are you a new immigrant?
Yes
No
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E. Citizenship Status |
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Canadian Citizen Aboriginal Landed Immigrant Convention Refugee Other
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F. Agreement |
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I confirm that:
-I make my permanent and principal home in Ontario.
-I will be living in Ontario for at least 6 months (183 days) in the
12-month period immediately after this application.
-If there is a change in name, address, immigration, or citizenship
status, I must tell the Ministry of Health within 30 days of the change.
-The information I have given in this application, and in the documents
I have provided, is true and accurate.
-The Ministry of Health may check my resident status and any
information I have given in this form and in the documents I have
provided.
I understand that:
-For verification, this form may be collected from, and disclosed to,
government and non-government organizations if the law allows it.
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Signature of applicant
parent
legal guardian
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Date
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