PARTICIPANT’S GWICH’IN COMMUNITY TRANSFER REQUEST

PARTICIPANT’S GWICH’IN COMMUNITY TRANSFER REQUEST

- STATEMENT OF CONSENT -
I am currently registered in the GCLCA under the following name *

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
m/d/y
Enrolment Number
Community With Which Participant is Presently Associated (Choose One)*

AklavikFort McPhersonInuvikTsiigehtchic
Community With Which Participant Wishes to be Associated (Choose One)*

AklavikFort McPhersonInuvikTsiigehtchic
Reason(s) for Requested Transfer*
Contact Information
Please provide either a Phone Number or Email Address (preferably both) so that we can contact you.
Phone Number*
Email*
example@example.com
Home Address
P.O. Box
Apt./Unit
Street No.*
Street Name *
City/Town*
Province/State*
Country*
Postal Code*
Mailing Address
Tick here if it the same as Home Address
P.O. Box
Apt./Unit
Street No.*
Street Name *
City/Town*
Province/State*
Country*
Postal Code*
If you want your minor child(ren) to transfer also, please list below:
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.

* In case of minor children both parents must sign the request for transfer.
Print Name of Applicant *
Date*

MonthDayYear
m/d/y
Signature of Applicant (If 19 years of age or older) *

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