Hart Application Form

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*

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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*
MM slash DD slash YYYY

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Hart Application Form

HIGH ARCTIC RELOCATEE PARTITION TRUST (“HARPT”)

Step 1 of 3

Section A

Section A

Mother

Father

Legal Guardian

Signature

Section B

Section C

Section D