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Hart Application Form
HIGH ARCTIC RELOCATEE PARTITION TRUST (“HARPT”)
Step 1 of 3
33%
Is the applicant an:
*
Adult
Minor
Section A
Applicant Information
Surname
*
Given Name(s)
*
Alias
Mother's Maiden Name
*
Gender
*
Male
Female
Date of Birth
*
DD
MM
YYYY
Mailing Address or House Number or P.O. Box Number
*
City/Community
*
Province
*
Postal Code
*
Country
*
Daytime Telephone
*
Alternative Telephone
The Applicant is either:
*
an original High Arctic Relocatee, the spouse of an original High Arctic Relocatee, or a child (biological or adopted) of the age of majority in the first degree of an original High Arctic Relocatee; or
a Descendant of the age of majority of original High Arctic Relocatee
Name of Relocatee
*
From the community of
*
Section A
Applicant (Minor)
Name of Minor
Surname
*
Given Name(s)
*
Gender
*
Male
Female
Date of Birth
*
DD
MM
YYYY
Mother
of minor
Surname
*
Given Name(s)
*
Mailing Address or House Number or P.O. Box Number
*
City/Community
*
Province/Territory
*
Postal Code
*
Country
*
Daytime Telephone
*
Alternative Telephone
*
Father
of Minor
Surname
*
Given Name(s)
*
Mailing Address or House Number or P.O. Box Number
*
City/Community
*
Province/Territory
*
Postal Code
*
Country
*
Daytime Telephone
*
Alternative Telephone
*
Legal Guardian
of Minor
Surname
Mailing Address or House Number or P.O. Box Number
Given Name(s)
City/Community
Province/Territory
Postal Code
Country
Daytime Telephone
Alternative Telephone
The Applicant (Minor) is a Descendant of original High Arctic Relocatee
Name of Relocatee
*
From the community of
*
Signature
I agree that all information provided in this application if accurate
*
I Agree
The Mother, Father or Legal Guardian of Applicant (Minor) agrees that the information entered is correct to the best of their knowledge
*
I Agree
Date
*
Section B
Proof of Identity
Identification # being provided
*
JBNQA Beneficiary Card Number
Nunavut Beneficiary Card Number
Medicare Card Number
Social Insurance Card Number
Other
Only 1 is required
JBNQA Beneficiary Card Number
*
Nunavut Beneficiary Card Number
*
Medicare Card Number
*
Social Insurance Card Number
*
Type of Card
*
Card Number
*
Section C
Payment Options
Please Check ONE (1) of the following options:
*
I will pick up my cheque at the Makivik Corporation Montreal office
Please mail my cheque to the above address
Section D
Declaration
Declaration
– I solemnly declare that all of the statements made and the information provided in this Application, as well as any supporting documents, are true. I agree to indemnify and hold harmless the Trustees of the HIGH ARCTIC RELOCATEES PARTITION TRUST from any liability that may arise from my direction to the Trustees of the HIGH ARCTIC RELOCATEES PARTITION TRUST for the payment of the per capita distribution of settlement funds. Furthermore, I consent to the collection, use and disclosure of the personal information of the Applicant by the Trustees of the HIGH ARCTIC RELOCATEES PARTITION TRUST solely for the purpose of authenticating the identity, membership registration, and accurate issuance of the per capita distribution payment to the Applicant.
I Agree to the declaration stated above
*
I Agree
Declaration
– I solemnly declare that all of the statements made and the information provided in this Application, as well as any supporting documents, are true. I agree to indemnify and hold harmless the Trustees of the HIGH ARCTIC RELOCATEES PARTITION TRUST from any liability that may arise from my direction to the Trustees of the HIGH ARCTIC RELOCATEES PARTITION TRUST (on behalf of the Applicant (Minor)) for the payment of the per capita distribution of settlement funds. Furthermore, I consent to the collection, use and disclosure of the personal information of the Applicant (Minor) by the Trustees of the HIGH ARCTIC RELOCATEES PARTITION TRUST solely for the purpose of authenticating the identity, membership registration, and accurate issuance of the per capita distribution payment to the Applicant (Minor).
The Legal guardian of the minor agrees to the declaration stated above
*
I Agree
Date
*
