Citizenship And Enrollment Renunciation Form - Uchucklesaht Tribe Page 2

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Enrollee # ____
Page 2 of 2
C. EXECUTIONS
Prescribed Individual Signature(s)
EXECUTION DATE
Signature of individual whose
Uchucklesaht Citizenship or Enrolment
under the Maa-nulth Treaty is being
renounced or his or her Parents/Legal
Guardian(s)
Y
M
D
Print Name, Address and
Print Name:
Occupation:
Print Name:
PRESCRIBED INDIVIDUAL CERTIFICATION:
Your signature constitutes a representation that you are a prescribed individual authorized to witness the
execution of this Notice of Renunciation.
FOR OFFICE USE ONLY
APPROVED ___________________
SIGNED BY CHAIRPERSON OF UCHUCKLESAHT TRIBE GOVERNMENT
DENIED
___________________
Date Signed: ______________________
APPROVED___________________
SIGNED BY CHAIRPERSON OF MAA-NULTH
DENIED
___________________
Date Signed: ______________________
ENROLLEE #______
00298434

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