Form Dcs-5 - Citizenship And Enrolment Notice Of Renunciation Form - Department Of Community Services Page 2

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C. EXECUTIONS
Prescribed Individual Signature(s)
EXECUTION DATE
Signature of individual whose Toquaht
Citizenship or Enrolment under the Maa-
nulth Treaty is being renounced or his or
her Parents/Legal Guardian(s)
Y
M
D
Print Name, Address and
Print Name:
Occupation:
Print Name:
PRESCRIBED INDIVIDUAL CERTIFICATION:
Your signature constitutes a representation that you are a prescribed individual authorized to witness the execution of this Notice of
Renunciation.
FOR CITIZENSHIP AND ENROLMENT REGISTRAR USE ONLY:
This notice was received and approved by the Citizenship and Enrolment Committee on __________________.
Citizenship and Enrolment Registrar
00621240

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