Fillable INDIGENOUS ANCESTRY DECLARATION Students FULL name and address (North Island College)

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INDIGENOUS ANCESTRY DECLARATION Students FULL name and address (North Island College)

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Country of origin: CANADA
File type: PDF

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Rev:
Oct 14, 2020
INDIGENOUS ANCESTRY DECLARATION
Student’s FULL name and address (print clearly)
NIC STUDENT NUMBER
NAME
FORMER NAME (If Applicable)
ADDRESS
BIRTH DATE (MMM-DD-YYY)
CITY
PROVINCE
COUNTRY
POSTAL CODE
PHONE NUMBER
E-MAIL ADDRESS
NORTH ISLAND COLLEGE PROGRAM:
Yes
No
Voluntary Disclosure:
Do you identify yourself as an Indigenous person?
If yes, are you: First Nations
Metis Inuit
I understand that this information, along with subsequent information, is collected under the authority of the College and
Institute Act. This information will be protected and used in compliance with the BC Freedom of Information and Protection of
Privacy Act for the purpose of admission, registration, research, and other purposes consistent with the mandate of the
institution.
__________________________________
Student Signature
Date (mmm-dd-yyyy)
FOR OFFICE USE ONLY
Date Received: ___________________________
Date Entered: ___________________________
Advisor Signature: __
____________________________________
RA Signature: ______________________________________
ImageNow Document Code: Demographic
Office of the Registrar
2300 Ryan Road
Co
urt
ena
y BC V9N 8N6
T: 1-800-715-0914
E: forms@nic.bc.ca
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INDIGENOUS ANCESTRY DECLARATION Students FULL name and address (North Island College)

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Completed 5 February 2021

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