PARTICIPANT’S GWICH’IN COMMUNITY TRANSFER REQUEST

PARTICIPANT’S GWICH’IN COMMUNITY TRANSFER REQUEST

- STATEMENT OF CONSENT -
I am currently registered in the GCLCA under the following name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
m/d/y
Enrolment Number
Community With Which Participant is Presently Associated (Choose One)
Community With Which Participant Wishes to be Associated (Choose One)
Reason(s) for Requested Transfer
Contact Information
Please provide either a Phone Number or Email Address (preferably both) so that we can contact you.
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Home Address
P.O. Box
Apt./Unit
Street No.
Street Name
City/Town
Province/State
Country
Postal Code
Mailing Address
P.O. Box
Apt./Unit
Street No.
Street Name
City/Town
Province/State
Country
Postal Code
If you want your minor child(ren) to transfer also, please list below:
Applicant Signature

I certify that the information provided is, to the best of my knowledge, true, correct and complete. I acknowledge that I am submitting this information voluntarily to update my enrolment file.

* In case of minor children both parents must sign the request for transfer.
Print Name of Applicant
Date

MonthDayYear
m/d/y
Signature of Applicant (If 19 years of age or older)
Please verify that you are human
Should be Empty: