Ratification Vote Application Form A: For Use By Band Members

Ratification Vote Application Form A: For Use By Band Members

If you have any questions regarding this application form please contact the Ratification Officer.
Personal Information of Applicant
Name of Applicant

First NameMiddle NameLast Name
Applicant Information
Date of Birth

MonthDayYear
Date
Treaty Status #
Contact Information of the Applicant
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Do you consent to the release of your name and contact information to Black LakeFirst Nation, Fond du Lac First Nation and Hatchet Lake First Nation for the purposes of providing more information regarding the Athabasca Denesųłiné Agreement?

YesNo
Enrollment Under another Land Claim Agreement, Self-Government Agreement or other Band List?
Are you enrolled under another land claim agreement in Canada?

No, I am not enrolled under another land claim agreement.Yes, I am enrolled under another land claim agreement.
If you selected “Yes”, you are not currently eligible to participate in this vote.
Are you enrolled under a Self-Government Agreement in Canada?

No, I am not enrolled under a Self-Government Agreement.Yes, I am enrolled under a Self-Government Agreement.
If you selected “Yes”, you are not currently eligible to participate in this vote.
Is your name on a Band List, other than the Band List for Black Lake First Nation,Fond du Lac First Nation or Hatchet Lake First Nation?

No, my name is not on a Band List, other than the Band List for Black Lake First Nation, Fond du Lac First Nation or Hatchet Lake First NationYes, my name is on a Band List, other than the Band List for Black Lake First Nation, Fond du Lac First Nation or Hatchet Lake First Nation
If you selected “Yes”, you are not currently eligible to participate in this vote.
Information Provided by Applicant
By signing below, I consent to the release of the information contained in this application to the Ratification Committee to verify my personal information and to determine my initial and continued eligibility to participate in the ratification vote. I also consent to the release of this application to the enrollment registrar for the purposes of enrolment should the Athabasca Denesųłiné Agreement come into effect
Desired Manner of Obtaining a Copy of the Agreements

I would like a physical copy of the Athabasca Denesųłiné Agreement, the Legacy Agreement and all related documentsI would like a digital copy of the Athabasca Denesųłiné Agreement, the Legacy Agreement and all related documents.
Should the Athabasca Denesųłiné Agreement be successfully ratified

Yes, I authorize the enrollment registrar to enroll me under the AthabascaDenesųłiné Agreement.No, I do not authorize the enrollment registrar to enroll me under theAthabasca Denesųłiné Agreement.
Nothing precludes an individual from enrolling or withdrawing their enrollment at a
later time.
Signature of Applicant
I certify that the information provided is, to the best of my knowledge, true, correct and complete.

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Complete all information requested on this form. This form must be completed in full to avoid any delays in processing. The Ratification Officer may request additional information to process this application. The onus is on the Applicant to notify the Ratification Officer of any changes to the information requested on this form.
One of the selections you've made above has made you ineligible to participate in the vote. If this is an error, please verify the above information was entered correctly.
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Ratification Vote Application Form A: For Use By Band Members

Personal Information of Applicant

Applicant Information

Contact Information of the Applicant

Enrollment Under another Land Claim Agreement, Self-Government Agreement or other Band List?

Information Provided by Applicant

Signature of Applicant