2014 GWA’SALA-‘NAKWAXDA’XW MEMBERS ANNUAL DISBURSEMENT (CHRISTMAS BONUS) INFORMATION APPLICATION FORM
PLEASE FILL OUT THIS FORM WITH ALL YOUR CURRENT INFORMATION: IT IS IMPORTANT FOR THE TRUST COMMITTEE, MEMBERSHIP DEPARTMENT TO HAVE IN ORDER TO PREPARE THE ANNUAL DISBURSEMENT CHEQUES. * THOSE WHO ARE 18 & OLDER ARE TO FILL OUT THEIR OWN APPLICATION FORM; THE CUT OFF DATE FOR FILLING OUT THIS FORM IS DECEMBER, 1ST, 2014 AS WE NEED TO HAND IN APPLICATIONS FOR PROCESSING ON DECEMBER 4TH, 2014* HOUSE NUMBER STREET ADDRESS IF LIVING OFF RESERVE PHONE NUMBER MAILING ADDRESS BOX PORT HARDY V0N2P0 Last Name
Name and Middle Initials
1 2 3 4 5 6 7 8 9 10 11 Signature: Council Signature: OFFICE USE ONLY PAYABLE TO:
Amount of Cheque:
*PLEASE DROP OFF @ BAND OFFICE*
Birthdate Year/Month/Day
GN Band Number