VAC VIP Application

VAC VIP Application — Your Profile (VAC1145APe)

Please read and complete Sections A, B, E and F. Sections C and D only if they apply to your personal situation. Fields marked with an asterisk are required.
Section A — Personal information
Title

Other
Other title
Mailing address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City / town / village
Country
Province / territory / state
Postal code / ZIP
Home telephone
Please enter a valid phone number.Format: (000) 000-0000.
Other telephone
Please enter a valid phone number.Format: (000) 000-0000.
Official language used in oral communications
Official language used in correspondence
Date of birth

MonthDayYear
Date
Are you a VAC employee?
Maiden name
Representative
Section B — Service information
Service No.(s) / RCMP Regimental No.(s)
Are you still serving?
Date of release

MonthDayYear
Date
Service history
Section C — Spouse/Common-law partner information
Only complete if applicable.
Marital status
Do you currently live with your spouse/common-law partner?
If no, explain the reason for involuntary separation
Spouse/common-law partner name

First NameMiddle NameLast Name
Spouse maiden name
Spouse title
Spouse date of birth

MonthDayYear
Date
Date marriage or common-law relationship began

MonthDayYear
Date
Does your spouse/common-law partner receive VAC disability or survivor benefits?
Spouse File No.
Spouse Service No.(s) / RCMP Regimental No.(s)
Section D — Dependent children information
Only complete if applicable.
Child 1 name (last, first, middle)

First NameMiddle NameLast Name
Child 1 date of birth

MonthDayYear
Date
Child 1 relationship to you
Child 1 residing with you?
Child 2 name (last, first, middle)

First NameMiddle NameLast Name
Child 2 date of birth

MonthDayYear
Date
Child 2 relationship to you
Child 2 residing with you?
Additional dependent children
Section E — Proof of identity
Include the required display text exactly as provided.
Type of document provided
Upload proof of identity

Cancelof
Section F — Declaration
Declaration
I agree to the declaration above.
Signature
Date

MonthDayYear
Date
Should be Empty:

VAC VIP Application — Your Profile (VAC1145APe)

Section A — Personal information

Section B — Service information

Section C — Spouse/Common-law partner information

Section D — Dependent children information

Section E — Proof of identity

Section F — Declaration