Pasqua Membership Form
Part 1:Personal Information (Print Clearly)
Name
*
First Name
Middle Name
Last Name
Status Number
*
Birth Date
*
-
Month
-
Day
Year
Date
Address
*
Street Address
P.O. Box/House Number
City
State / Province
Postal / Zip Code
Email Address
*
example@example.com
Home Phone / Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Benefits Claim Form
Part 2: Benefits Compensation Payment
I, hereby authorize Pasqua First Nation to send any payments I may be entitled to, as directed below.
*
(Print Full Name)
Select Method of Payment: (Check One Only)
*
Electronic Funds Transfer (EFT)
Paper Cheque
Has your banking information changed from last payment
*
Yes
No
Has your banking Information been Submitted to Finance (If you select No - Please email direct deposit form from bank or void cheque to memberinfo@pasquafn.ca)
*
Yes
No
Full Name on Bank Account
*
Submit
Should be Empty: