Quality of Life Survey

Name *

First Name

Last Name

Membership Number

Gitlaxdax Nisga'a Terrace Society Membership number.

(###)

###

####

Currently Employed

Yes

No

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Annual house hold income

(before taxes)

$0 - $47,937

$47,938 - $95,875

$95,876 - $110,076

$110,076 - $133,644

$133,645 +