Form Ca-1001-V - Registration Application For Indians
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CA -1001-V
2012 -0 5
1 of 2
Registration Application for Indians
Program for Administering the Fuel Tax Exemption for Indians
Erase
Use this form only if you are an Indian within the meaning of
ments may cause your application to be denied or delay the issuance
the Indian Act and you wish to apply for the Attestation d’inscription
of your registration card.
(registration card) required to benefit from the Program for Administer-
Filing an application
ing the Fuel Tax Exemption for Indians. The program was introduced
so that Indians, band councils, tribal councils and band-empowered
Send this form, duly completed, and the copy of both sides of your
entities can purchase fuel on Indian reserves or in Indian settlements in
Certificate of Indian Status to one of the following addresses:
Québec without having to pay the fuel tax.
• 3800, rue de Marly
Québec (Québec) G1X 4A5
Online services
• C. P. 3000, succursale Place-Desjardins
Instead of using this form, you can apply using the online services
Montréal (Québec) H5B 1A4
available on our website, at Doing so will
speed up the processing of your application.
Request for modification or replacement
If you wish to modify your registration information, or if you need your
Providing a copy of your Certificate of Indian Status
registration card to be replaced, either use the online services available
on our website or complete form CA-1001.M-V, Request to Modify
You must enclose a copy of both sides of your Certificate of Indian
Registration Information or to Replace the Attestation d’Inscription
Status issued by Aboriginal Affairs and Northern Development Canada
Issued to Indians .
(AANDC) [formerly Indian and Northern Affairs Canada (INAC)] with
your application; otherwise, your application will be rejected.
Request for information or forms
Providing the required information
For more information, or to obtain copies of forms, go to our website
or contact our client services at 418 659-4692 (Québec City region),
If you do not provide us with your name and address or if the infor-
at 514 873-4692 (Montréal region), or, toll-free, at 1 800 567-4692
mation provided is not valid, your application will not be processed.
(other regions).
Moreover, failure to provide us with all required information and docu-
1
Information about the applicant
Certificate of Indian Status number
Last name
1
2
First name
3
Date
of birth
Gender
Language of communication
4
5
Male
Female
6
French
English
Home address
Apartment
Number
Street, P.O. box
7
City, town or municipality
Province
Postal code
8
9
Driver’s licence number (optional)
Social insurance number (if you have one)
10
11
Continued
.
Do not use this area
N
C
L
99
10V C ZZ 4 948 8 6 6 7
Form prescribed by the President and Chief Executive Officer
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