Personal Information

A dependent is a child below the age of 16 or an adult who may have a mental and/or physical limitation and depends on assistance to carry out regular activities, obtain services, as well as access and protect their rights. If they are 16 and above, they will need to fill out this form themselves.

I hereby certify that I understand:

1. I am requesting and providing consent to Canada to be added to the initial section 11 Band List of the proposed Michel Callihoo Nation,

2. This Statement of Intent is solely for the purposes of supporting MCNS in seeking recognition of the Michel Callihoo Nation as Indian Band under section 17 of the Indian Act, and

3. That this Statement of Intent is not an application for registration under the Indian Act and MCNS and Canada can in no way guarantee that I will qualify for recognition as a member of the proposed Michel Callihoo Nation

and that I believe all answers herein to be true and accurate to the best of my knowledge.