Form-C-Modification Page 2
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1
2Form C - Enrolment Modification and Correction Form
Section C
Please indicate ONLY the element you wish to modify or correct
(cont’d)
Modification
Correction
Marital Status
Single
Married
Common Law
Separated
Divorced
Widow
Date of Event (yy/mm/dd)
(please attach supportive document)
Family Name of Consort
Given Name(s)
Date of Birth of Consort (yy/mm/dd)
Beneficiary No. Consort
SIN No. Consort
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)
Has the person concerned filed any application form to a
Application A: New Enrolment (Adult)
Community Enrolment Committee and/or Nunavik Enrolment
Application B: New Enrolment (Child)
Review Committee within the last twelve (12) months of the
Community
Application C: Modification - Correction
date of the present Application?
Yes
No
Application D: Re-Establishment Residence in Nunavik
Application E: Removal from Nunavik Inuit Beneficiary List
(if YES, please specify)
Application F: Request to Review a Decision
Date
Section D
DECLARATION & SIGNATURE OF APPLICANT
I hereby declare that the information contained in this Application
is accurate and true to the best of my knowledge.
X
Supportive documents enclosed:
Yes
No
Signature of Applicant
Place of Signature
(yy/mm/dd)
Section E
RESERVED TO THE COMMUNITY ENROLMENT COMMITTEE ONLY
THIS APPLICATION HAS BEEN REVIEWED BY THE ______________________________________ ENROLMENT COMMITTEE
Approved
Not approved
Missing Information
AND HAS BEEN:
Reasons for not approving:
Not a Canadian citizen
Not an Inuk according to Inuit customs and traditions
Does not indentify himself as an Inuk
Is not associated with the community
Is enrolled at other Land Claim Agreement or Treaty
Other (specify below):
X
Place of Signature
Date
Signature of the Community Enrolment Secretary
Community Enrolment Committee
SECTION RESERVED TO NUNAVIK ENROLMENT OFFICE
Registered into the Nunavik Inuit Beneficiaries Register Yes
Decision No.
Date: _______________________________
INITIALS: ___________
One signed copy for (1) the Applicant - (2) Community Enrolment Committee
Nunavik Enrolment Office
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