APPLICATION FOR ENROLMENT

Section A

This form is for:

Section B

The information on this form is provided by:

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

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

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

Format: (000) 000-0000.

2nd Contact #:

Format: (000) 000-0000.

Fax

Format: (000) 000-0000.

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 Community

Treaty Number

Metis Community

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

Other Enrollment:

Section F

Which community would you like to be associated with?

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).

Rows	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).

Rows	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

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