Request for Non-Publication in The Ontario GazettePlease right

Office of the Registrar General
PO Box 3000
189 Red River Road
Thunder Bay ON P7B 5W0
Request for Non-Publication in The Ontario Gazette
Section 6, Regulation 68, Change of Name Act, 1990
To be completed and signed by the applicant and included with the Change of Name application form.
To the Registrar General:
Complete this section if you are submitting a Request to Change an Adult’s Name (subs. 4(1), CNA)
I,
Full name of applicant
, am the person applying for a
name change for myself. I hereby request that notice of the change of name not be published in The Ontario Gazette because, at
the time of this application, I am a transgendered individual.
Complete this section if you are submitting a Request to Change a Child’s Name (subs. 5(1), CNA)
I,
Full name of applicant
name change for
, am the person applying for a
.
Current full name of child
I hereby request that notice of the change of name not be published in The Ontario Gazette because, at the time of this
application, the person to whose name the application relates, is a transgendered individual.
Signature of Applicant
Date (yyyy/mm/dd)
Personal information on this form is collected under the authority of the Change of Name Act, R.S.O. 1990, c.C.7. It may be used to determine
whether a change of name should be published in The Ontario Gazette and for statistical, research and law enforcement purposes as
applicable. Questions about this collection should be directed to: The Deputy Registrar General, Office of the Registrar General, PO Box 4600,
189 Red River Road, Thunder Bay ON P7B 6L8. Telephone - Toll-free: 1 800 461-2156; Toronto: 416 325-8305; TTY Toll-free: 1 800 268-7095;
TTY Toronto: 416 325-3408.
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11320E (2012/10)
© Queen's Printer for Ontario, 2012
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