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
Format: (000) 000-0000.
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):
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
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).
Please verify that you are human
Should be Empty:

APPLICATION TO CHANGE NAME