APPLICATION TO CHANGE ADDRESS IN GCLCA

APPLICATION TO CHANGE NAME

IN THE GWICH’IN COMPREHENSIVE LAND CLAIM AGREEMENT
Full Name*

First NameMiddle Name(s)Last Name
Enrolment Number
1234
Date of Birth*

MonthDayYear
Date
Please provide either a Phone Number or Email Address (preferably both) so that we can contact you.
Phone Number*
Email*
example@example.com
Health Care Number
SIN Number
Change my name to the following:
Name*

First NameMiddle Name(s)Last Name
Reason for Name Change (Check one):*

MARRIAGE (please attach copy of marriage certificate)DIVORCE (please attach copy)OTHER (please attach copies of supporting documentation)
Upload Supporting Document(s)*

Cancelof
Home Address
P.O. Box
Apt./Unit
Street No.*
Street Name*
City/Town*
Province/State*
Country*
Postal / Zip Code*
Mailing Address
Tick here if it the same as Home Address
P.O. Box
Apt./Unit
Street No.*
Street Name*
City/Town*
Province/State*
Country*
Postal / Zip Code*
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.
Print Name of Applicant*
Date*

MonthDayYear
Date
Signature of Applicant (If 19 years of age or older).*

Clear
Please verify that you are human*
Should be Empty:

APPLICATION TO CHANGE NAME