Sworn Declaration - Review of Applications for Membership in The Qalipu Mi'kmaq First Nation

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Privacy Act Statement

The information provided in this document is collected under the authority of the Agreement for the Recognition of the Qalipu Mi'kmaq First Nation Band and the Indian Act, 1985 R.S.C. I-5, for the purpose of identifying and registering the Founding Members of the Qalipu Mi'kmaq First Nation. The personal information that is provided is used by the Members and Clerks of the Enrolment Committee and by the employees of the Office of the Indian Registrar of Aboriginal Affairs and Northern Development Canada (AANDC), and will be retained by AANDC for an indefinite period of time. Individuals have the right to the protection of and access to their personal information under the Privacy Act, R.S.C. 1985, c.P-21. The collection, use, disclosure and retention of personal information are described in the Personal Information Bank INA PPU 110, online at InfoSource. By signing this application, the applicant (or his or her parent/legal guardian, if the applicant is a minor; or legal guardian, if the applicant is a dependent adult) hereby consents to the collection, use, disclosure and retention of the personal information provided herein in accordance with the above.

Notice to All Applicants

This form must be completed for each applicant submitting supporting document(s) as evidence of the applicant’s frequent visits and/or communications with resident members of the Mi’kmaq Group of Indians on the island of Newfoundland and of the applicant’s maintenance of the Mi’kmaq culture or way of life (i.e., evidence of acceptance as a Member of the Mi’kmaq Group of Indians of Newfoundland).   See section 12 of the Directive to the Enrolment Committee and the Appeal Master(s) with respect to the application of paragraph 4(1)(d)(ii) of the Agreement for the Recognition of the Qalipu Mi’kmaq Band relating to acceptance as a Member of the Mi’kmaq Group of Indians of Newfoundland.

For applicants under the age of 18 at time of application, fulfillment of the criterion of acceptance as a Member of the Mi’kmaq Group of Indians of Newfoundland may also be based on documentation demonstrating that at least one of their parents had been accepted as a Member of the Mi’kmaq Group of Indians of Newfoundland.

Part 1: Personal Information


Complete the following only if this Sworn Declaration is in support of a Child/Dependent Adult Application








Part 2: Statement



Part 3: Supporting Documentation

(Please use additional sheets as required)

Please provide information that we could use to contact you













Part 4 : Declaration

(This form is to be signed in front of a lawyer, justice of the peace, notary public, commissioner of oaths or other officer authorized to take oaths in the jurisdiction.)

Officer authorized to take oaths - Information and Declaration