APPLICATION TO CEASE TO BE ENROLLED

APPLICATION TO CEASE TO BE ENROLLED

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

First NameMiddle Name(s)Last Name
Date of Birth*

MonthDayYear
Date
Enrolment Number
1234
Gwich'in community you are associated with*

AklavikFort McPhersonInuvikTsiigehtchic
Please provide either a Phone Number or Email Address (preferably both) so that we can contact you.
Phone Number*
Email*
example@example.com
Mailing Address
P.O. Box
Apt./Unit
Street No.*
Street Name*
City/Town*
Province/State*
Country*
Postal / Zip Code*
Declaration
I, {fullName}, declare that;
1. I am enrolled as a participant pursuant to Chapter 4 of the Gwich’in Comprehensive Land Claim Agreement; and
2. I am associated with the community of {gwichinCommunity83}, NWT; and
3. My enrolment number is {enrolmentNumber}, and
4. I am of the age of majority; and
5. I would like to cease to be enrolled as a participant pursuant to Chapter 4 of the Gwich’in Comprehensive Land Claim Agreement effective immediately; and
6. I would like my name removed from the Gwich'in Enrolment Registry; and
7. I understand and agree that this is a one time withdrawal and I will NOT be entitled to any rights, benefits, interests or privileges accorded to Gwich’in, now or in the future, pursuant to the Gwich'in Comprehensive Land Claim Agreement, or according to the Gwich'in Tribal Council policy or directives.
Gwich'in ID Card Return*

I was provided with a Gwich'in ID Card and I shall return this card to the Gwich'in Enrolment Office.I was not provided with a Gwich’in ID Card.
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
Name of Witness*
Date*

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

Clear
Signature of Witness (If 19 years of age or older).*

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