Gift Application Form

Legal Name:

Date of Birth:

Spouse (if a band member)

Date of Birth:

Dependents (Minor children under the age of 18). Are these children in your care?

Yes

No

Partially

Dependents Legal Name:

Date of Birth:

By signing this application, you are declaring that your information provided is true. Any false information can jeopardize your cheque of gift now, and in the future.

Address:

City:

Province

Postal Code:

Phone:

Email:

Signature:

Date:

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Lax Kw’alaams Band

206 Shashaak Street
Lax Kw’alaams, BC V0V 1H0

Phone: 1.877.725.3293

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