Citizenship And Enrollment Renunciation Form - Uchucklesaht Tribe
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1
2Enrollee # ____
UCHUCKLESAHT TRIBE
Date received:
Citizenship Act
Department of Human Services
Form DHS-5
(for Uchucklesaht Tribe
Registrar Use Only)
CITIZENSHIP AND ENROLMENT
NOTICE OF RENUNCIATION FORM
A. PERSONAL INFORMATION
Full Name of individual whose Uchucklesaht Citizenship or Enrolment under the Maa-nulth Treaty is
being renounced:
Full Name:
Citizenship Number:
Enrolment Number:
Full Name of Parents or Legal Guardian(s) if different from Parents: (where the individual whose
Uchucklesaht Citizenship or Enrolment under the Maa-nulth Treaty is being renounced is a child or an adult
for whom a committee has been appointed under the Patients Property Act (British Columbia))
Parent/Legal Guardian 1:
Parent/Legal Guardian 2:
Address:
City:
Province/State:
Code:
Telephone Number:
E-mail Address:
B. RENUNCIATION
I HEREBY FREELY, WITHOUT THREAT, PROMISE OR COMPULSION, ABSOLUTELY AND
UNCONDITIONALLY RENOUNCE MY: (please check one)
Uchucklesaht Citizenship
Enrolment under the Maa-nulth Treaty
Uchucklesaht Citizenship and Enrolment under the Maa-nulth Treaty
00298434
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