Form-C-Modification
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1
2Form C
Enrolment Modification
and Correction Form
Nunavik Enrolment Office
P.O. Box 179
Nunavik Enrolment Office established under the authority of the Makivik Board of
Kuujjuaq, Nunavik (Quebec) J0M 1C0
Directors is responsible to maintain the Nunavik Inuit Beneficiaries Register
Tel: (819) 964-2925 Fax: (819) 964-0458
Website:
(if the Applicant is the same as the Person Concerned, please skip
Section A
IDENTIFICATION OF THE APPLICANT
Section A and go directly to Section B)
Female
Male
Applicant Family Name
Applicant Middle name
Applicant Given name(s)
Home Tel.:
Work Tel:
Date of Birth (yy/mm/dd)
Place of Birth
Community Affiliation
Community of Residence
Address of Residence
City
Province/Territory
Postal Code
Relationship to the Person Concerned
Person Concerned
Other (specify)
Beneficiary No
Social Insurance No.
Health Care Card No.
Section B
INFORMATION OF THE PERSON CONCERNED
Female
Male
Family Name
Middle name
Given name(s)
Home Phone No.
Work Phone No.
Date of Birth (yy/mm/dd)
Place of Birth
Beneficiary No.
Total Years of Residence "Outside
Address of Residence
City
Province/Territory
Postal Code
Territory" (if applicable)
"N" Number Health
Community of Residence
Community Affiliation
Social Insurance No.
Health Care Card No.
Canada (if Applicable)
Section C
Please indicate ONLY the element you wish to modify or correct
Modification
Correction
Female
Male
Family Name
Middle name
Given name(s)
Home Phone No.
Work Phone No.
Date of Birth (yy/mm/dd)
Place of Birth
Beneficiary No.
Total Years of Residence "Outside
Address of Residence
City
Province/Territory
Postal Code
Territory" (if applicable)
"N" Number Health
Community of Residence
Community Affiliation
Social Insurance No.
Health Care Card No.
Canada (if Applicable)
Nunavik Enrolment Office
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