Name
*
First Name
Last Name
Mailing Address
*
or Box Number/Unit Number
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Address
(If different to mailing address)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
###
####
Maiden Name
Gender
Date of Birth
MM
DD
YYYY
Place of Birth
Age
Are you the head of your household?
*
Do you live On-Reserve?
*
Number of Minor Dependants:
*
0
1
2
3
4
5
6
7
8
9
10+
Number of Individuals in your Household
*
1
2
3
4
5
6
7
8
9
10+
What is your current occupation?
*
Self-Identification (check off)
*
Check off the self-identification(s) that applies to you from the following:
Are you currently a member of a First Nations, Inuit, or Metis community/organization?`
*
If yes, with whom do you have a membership with?
*
How did you hear about the ICAA Individual Membership?
Please indicate what issues or areas of concern you would like the ICAA to focus its attention on, for yourself and your community.
Legal Declaration
*
I make a declaration that I am:
1:
*
2:
*
3:
*
4:
*
5:
*
6:
*
Would you like the ICAA to keep you informed on our events and activities going forward?
*
Permission
*
Signature
*
Date of Application
*
MM
DD
YYYY
Application Attachments
*
Check off one of the following. Note: applications will be considered incomplete without the submission of application attachments.
