Application to Access Gwich'in Private Lands

Application To Access Gwich’in Private Lands
Type of Application
Application #:
Company/Application Name:
Company Registration #:
Phone Number
Format: (000) 000-0000.
Mobile
Format: (000) 000-0000.
Fax
Format: (000) 000-0000.
Address:

Address Line 1

Address Line 2 or P.O Box

CityState / Province

Postal / Zip CodeCountry
Email
example@example.com
Have you been in contact with the following? (enter date of contact below)ov
Gwich’in Land and Water Board

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gwichya Gwich’in Council (Tsiigehtchic)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gwich’in Land Use Planning Board

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Ehdiitat Gwich’in Council (Aklavik)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gwich’in Renewable Resource Board

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Nihtat Gwich’in Council (Inuvik)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Department of Culture and Heritage

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Tetlit Gwich’in Council (Fort McPherson)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Purpose of application:
Description of operation type of undertaking proposed: (check the following). Please Note: There might be fees associated with the type of operation. Please refer to GLR Fee Schedule found here: https://www.gwichintribal.ca/forms.html

Other

Period of operation (include all phases of project, work applied for, including restoration).

Rows	Activity	Earliest Start date	Latest Start Date	Earliest Finish Date	Latest Finish Date
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Describe the operation (as much detail as possible).
Location of activity (describe):

Rows	Gwich’in Settlement Lands Parcel #	Latitude	Longitude
1
2
3
4
5

Upload file(s) with location data - Max 100mb (pdf, xls, xlsx, csv, kmz, kml, zip) - Zip Multiple Files

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Describe access to site (be specific, indicating use of new or existing routes and if the access has been ground truthed):
Provide a description of any camp(s) (if applicable):
Describe your disposal method for garbage, sewage, trees, bush and overburden:
Water use (list and describe all required uses of water during the activity, estimated volume and the location of the source):
During the proposed activity, will you be required to do any of the following?
Describe how you propose to conduct the above-listed activities:
List equipment for all activities and their proposed use (including drills and pumps, etc.)
List all fuels and other hazardous materials and method of storage used:
Containment and spill contingency plans
Calculations of area involved (include access, staging area, airstrips, camp sites, etc.):
List of other contractors:
List of personnel:
Environment and/or resource impacts and proposed mitigation for all disturbances and impacts:
Identify any monitoring programs:
Restoration plans and proposed restoration for all disturbances and impacts:
Authorized Representaive
Applicant (Print Full Name)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gwich'in Tribal Council (for GLR use only)
Accepted By
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Remarks
Application Fee
Date Received

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please verify that you are human
Should be Empty:

Application To Access Gwich’in Private Lands