APPLICATION FOR ENROLMENT

Section A

This form is for:*

a person eligible for enrolment pursuant to section 4.2.1 of the GCLCA.a minor eligible for enrolment pursuant to section 4.2.1 of the GCLCA.

Section B

The information on this form is provided by:*

the Participantthe parent or guardian of a minor childa family membera Designated Gwich’in Organization

Section C

Name*

First NameMiddle Name(s)Last Name

Date of Birth (if unsure - give an estimate)*

Date

Maiden Name

Original Family Name (if adopted):

Sex*

MaleFemale

If you were unsure of Date of Birth - check which part you are unsure of.

DayMonthYear

Place of Birth*

Health Care #

Social Insurance #

Section D

P.O. Box*

Apt./Unit*

Street Number*

Street Name*

City / Town / Community*

Province / Territory / State*

Postal Code / Zip Code*

Country*

Email

example@example.com

Phone

2nd Contact #:

Fax

Section E

Indicate whether you are on an Indian Act Band or Métis Local membership list in a community within the Gwich’in Settlement Area (mark any box which applies to you):*

Gwich’in Indian Act Band (indicate community below):Treaty Number (Type Number below):Métis Local (indicate community):Applied for status under Bill C-31

Gwich’in Indian Act Band Community

Treaty Number

Metis Community

Indicate – if applicable – whether you are presently enrolled in any other comprehensive land claim:

InuvialuitSahtuYukonInuit

Other Enrollment:

Section F

Which community would you like to be associated with?*

Tsiigehtchic (Arctic Red River)Tetlit Zheh (Fort McPherson)AklavikInuvik

Section G

Please complete as much of the following as you can: where information is not known, please indicate as such. Indicate each relative’s ethnicity, e.g. Dene (Gwich’in, Slavey, Cree, etc.), Inuvialuit, Inuit, Metis, Non-Native, or Other (specify).

	Mother	Grandmother	Grandfather
Last Name
First Name
Maiden name
Place of Birth
Date of Birth (MM/DD/YYYY)
Ethnicity
Enrolment #

Section H

Please complete as much of the following as you can: where information is not known, please indicate as such. Indicate each relative’s ethnicity, e.g. Dene (Gwich’in, Slavey, Cree, etc.), Inuvialuit, Inuit, Metis, Non-Native, or Other (specify).

	Father	Grandmother	Grandfather
Last Name
First Name
Maiden name
Place of Birth
Date of Birth (MM/DD/YYYY)
Ethnicity
Enrolment #

Section I

I declare that I am a Canadian citizen; a Gwich’in as described in section 4.1.1 of the Gwich’in Comprehensive Land Claim Agreement; I am the age of majority; I am eligible for enrolment under section 4.2.1 of the GCLCA; and I wish to be enrolled under the GCLCA.

Applicant Signature*

Witness Signature*

Date*

Date

Witness (print name):*

Please upload a copy Applicant's Long Form Birth Certificate*

*Certificate of Canadian Citizenship (*if born outside of Canada)

Section J (If applying on behalf of a minor)

I declare that I am making this application on behalf of a minor for whom I am a parent or legal guardian.

Applicant Signature

Witness Signature

Date

Witness (print name):

Please verify that you are human*