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					                                                                                     500 Old St. Patrick St, Unit D
                                                                                        Ottawa, Ontario K1N 9G4
                                                                                            Tel:       613-798-1488
                                                                                            Toll Free: 800-263-4889
                                                                                            Fax:       613-722-4225

Please print clearly and send by land mail (not fax) to the Registry branch at the above address.
*You should send a recent photo if your previous card was issued more than three years ago.

I hereby request a replacement citizenship card from the Métis Nation of Ontario.

My Citizen number is: ________________                    Need replacement Harvest Card    _ Yes _No
Full Name: _____________________________________                      Date of Birth: ___________________
                (PLEASE PRINT CLEARLY)                                              (MONTH / DAY / YEAR)
Reason for Change: Please check all that apply.
_ Moved             _ Card lost            _ Card stolen
_ Photo update (New photo must be clear)   _ Wrong information on card
_ Name changed from ___________________________ to ________________________________
New Contact Information: P.O. Box or RR Number: _______ Apartment or Unit Number: _______
Street Address: ____________________________________________________________________
City/Town: ____________________________________Province:                      ON   (Ontario Residents Only)
Postal Code: __________________ Phone Number: ____________________________________
Please provide your e-mail address to receive periodic announcements via email from MNO.
E-mail address: _________________________________________________
Declaration: Please accept this as my written confirmation that I solely support the Métis Nation of
Ontario. I have no affiliation or membership card with another Métis or First Nation organization.

                                                                                     Please sign in the
            This is to certify that the Bearer of this Card is                      “Citizen’s signature”
           recognized as a Métis within the meaning of the                              section ONLY
           Registry Process of the Métis Nation of Ontario.                               (blue ink)

                           Citizen’s Signature

                                                                               The Registrar and Date of Issue
                                Registrar                                      sections are reserved for MNO

                              Date of Issue