Name * First Name Last Name Citizenship Number Phone (###) ### #### Birthdate * MM DD YYYY Email * Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country Mailing Address is same as Home Address? * Yes No Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country Child(ren) Name, Gender, DOB Agreement Acknowledgment * I agree that by submitting this document, I confirm I have completed this form truthfully and accurately to the best of my ability. Also by submitting; I give consent for the Gitlaxdax Nisga’a Terrace Society to share my information to confirm items pertaining to this application. I agree Thank you!Reimbursements are available Via E-Transfer or Cheque on the Third Friday of every month.
