Application for membership to the Native Alliance of Quebec

Application for membership
to the Native Alliance of Quebec
Applicants for membership to the Native Alliance
of Quebec are responsible for providing
all necessary documented proof of aboriginal ancestry
1- 1- Status Indians permanently residing off reserve :
A) Copy of status card.
B) Copy of birth certificate.
2- 2- Non status Indians :
A) Copy of parent or grand-parent status card.
B) Copy of birth / marriage certificates required to prove direct link.
3- Metis :
A) Copy of documented proof of aboriginal ancestry, Indian, Inuit or Metis.
B) Copy of birth / marriage certificates required to prove direct lineage to the aboriginal ancestor
or :
C) A genealogy (family tree) prepared and certified by an accredited genealogist.
NOTE : Only original copies with seal are accepted.
4- Please note that only copies of original certificates or documents will be accepted. Certificates or
documents which have been altered, modified or added to, will be automatically rejected.
5- All applications must be done through communities of the Native Alliance of Quebec, signed by local membership revision committee and sent to the Native Alliance of Quebec by appropriate channels.
NOTE : Applications send to the Native Alliance of Quebec by individuals will be refused and returned.
All applications must be in full conformity to the rules of the Citizenship Code of our Nation.
Identification
Your picture
Max 2” X 2¾”
Please provide a passport size color picture and sign your name clearly (using black ink) in one of the
rectangles on the right. YOUR SIGNATURE MUST BE CONTAINED WITHIN THE LINES OF THE RECTANGLE.
Date of request : ____________________
Questionnaire
regular member
Registration number of member:_________________ E-mail (if avalaible) : _________________________________
1. Surname : __________________________________
Given name : ___________________________________
2. Community number : ________________________
3. Community name : ________________________________________________________________________
4. Address : _____________________________________________________________________________________
5. City : ___________________________________________
Postal code : _______________________________
6. Telephone number : ____________________________
Date of birth : __________________________
7. Social insurance number : ________________________
Sex :
M : _________
F : _________
8. Your Native origins are from :
Father : _______
Mother : _______
Both : ______ (If from both provide proof from both sides)
9. From which aboriginal group do you originate from :
Status : ______
Non-status : ______
Metis : ______
Inuit : ______
10. If you are a status Indian :
Band N° : ____________
Nation : ________________________________
11. If you are a non-status indian, please indicate from which nation you are affiliated with :
Nation : __________________________________________________________
12. What are your proof and documents? ____________________________________________________________
13. I you are a Metis, identify the nation of origin of your ancestors ? ________________________________________
14. Complete name of the non-aboriginal spouse : ______________________________________
VERIFICATION
COMMUNITY
PROVINCIAL
1. Questionnaire A, B, C et D complete
2. Documents and proofs
3. Signature of the community committee
4. Identify photo certified at back by revision comity
member
Verified by : _____________________________________ Verified by : _____________________________________
Community
Provincial
Questionnaire
regular member (following)
UNDER 16 years of age?
Yes
No
If “yes”, indicate age below
Age
1.
1
7
13
2
8
14
3
9
15
4
10
5
11
5
12
2.
1
7
13
2
8
14
3
9
15
4
10
5
11
6
12
3.
1
7
13
2
8
14
3
9
15
4
10
5
11
6
12
4.
1
7
13
2
8
14
3
9
15
4
10
5
11
6
12
5.
1
7
13
2
8
14
3
9
15
4
10
5
11
6
12
6.
1
7
13
2
8
14
3
9
15
4
10
5
11
6
12
7.
1
7
13
2
8
14
3
9
15
4
10
5
11
6
12
Questionnaire
regular member (following)
Do you have children OVER 16 years of age?
Yes
No
If “yes”, please write down their coordinates below.
Name
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Address
Telephone number
Name of the applicant : __________________________________________
Great-great-grandfather
Great-grandfather
Grandfather
______________________
_________________________
Great-great-grandmother
_________________________
______________________
Great-great-grandfather
Great-grandmother
_________________________
______________________
Great-great-grandmother
_________________________
Mother
___________________________
Great-great-grandfather
Grandmother
Great-grandfather
_________________________
______________________
Great-great-grandmother
_________________________
______________________
Great-great-grandfather
Great-grandmother
_________________________
______________________
Great-great-grandmother
_________________________
Name of the applicant : __________________________________________
Great-great-grandfather
Great-grandfather
Grandfather
______________________
_________________________
Great-great-grandmother
_________________________
______________________
Great-great-grandfather
Great-grandmother
_________________________
______________________
Great-great-grandmother
_________________________
Father
___________________________
Great-great-grandfather
Grandmother
Great-grandfather
_________________________
______________________
Great-great-grandmother
_________________________
______________________
Great-great-grandfather
Great-grandmother
_________________________
______________________
Great-great-grandmother
_________________________
BUTS ET OBJECTIFS DE
AIMS AND OBJECTIVES OF
L’ALLIANCE AUTOCHTONE
DU QUÉBEC INC.
THE NATIVE ALLIANCE
OF QUEBEC INC
Notre association, fondée en 1972, vise à regrouper les Métis et
Indiens hors réserve du Québec et parler en leur nom. Bien que
nous sommes de race amérindienne, nous ne sommes
majoritairement pas considérés comme tels selon l’Acte Indien
Fédéral.
Our association, founded in 1972, aims to regroup the Metis
and off reserve Indians of Quebec and to speak in their name.
Although of Amerindian ancestry, we are in majority not
considered as such under the Federal Indian Act.
1.) Notre association vise la promotion et la défense des droits
et intérêts des Métis et Indiens hors réserve du Québec.
2.) Notre association veut obtenir la reconnaissance du peuple
des Métis et Indiens hors réserve par tous les paliers du
gouvernement et par les citoyens canadiens en général.
3.) Notre association veut donner aux communautés locales les
outils nécessaires pour assurer leur épanouissement
individuel et collectif dans toutes les sphères d’activités
économiques, sociales et culturelles du Québec.
4.) Notre association travaille à l’égalité des chances
pour tous, d’accéder à l’éducation, d’avoir des programmes
scolaires répondent aux goûts et aspirations de nos jeunes.
5.) Notre association travaille à l’égalité des chances pour
tous, de pouvoir gagner sa vie décemment et cesser
d’être du même coup dépendant des gouvernements.
6.) Notre association travaille à l’égalité des chances pour tous
de faire valoir, dans tous les aspects de vie personnelle et
collective, sa fierté d’appartenir à la culture autochtone.
7.) Notre association travaille à l’égalité des chances pour tous
d’occuper un logement décent.
8.) Notre association travaille à l’égalité des chances pour tous à
la justice.
9.) Notre association travaille à bâtir une organisation où chacun
des Métis et Indiens hors réserve participera dans
l’intérêt de la nation à laquelle il est fier d’appartenir.
Conscient des buts et objectifs de l’Alliance Autochtone du
Québec Inc. j’adhère à cette association et m’engage à respecter
sa CONSTITUTION et ses règlements. En outre, je m’engage à
m’identifier comme autochtone constamment, et de
promouvoir dans toutes les occasions qui me sont possibles, la
NATION MÉTIS ET INDIENS hors réserve du Québec.
Signature du demandeur
Date
1.) Our association aims at promoting and defending the rights
and interests of the Metis and off reserve Indians of Quebec.
2.) Our association aims to obtain recognition for the Metis and
off reserve Indian Nation by all levels of
government and by Canadian citizens in general.
3.) Our association aims at giving our communities the
necessary tools to insure their collective and individual
development in all spheres of economic, social
and cultural activities within the province of Quebec.
4.) Our association aims to obtain equal opportunity for all to
have access to education and to school programs
answering to the needs and aspirations of our youth.
5.) Our association aims to obtain equal opportunity for all
to earn a decent living and, therefore, cease to be dependent
on governments.
6.) Our association aims to obtain equal opportunity for all to
enforce in the aspects of their personal and collective
lives their pride in being part of the native culture.
7.) Our association aims to obtain equal opportunity for all to
occupy a descent home.
8.) Our association aims to obtain equality of treatment within
the judicial system.
9.) Our association aims to build an organization where
every Metis and off reserve Indian will participate in the
interest of the nation of which he is proud to belong.
Being fully aware of the aims and objectives of the Native
Alliance of Quebec Inc. I adhere and commit myself to respect its
CONSTITUTION and bylaws. Furthermore, I am committed to
identify myself at all times as an aboriginal person and promote
on all possible occasions the Metis and off reserve Indian nation
of Quebec.
Signature of the applicant
NOM EN LETTRE MOULÉES
NAME IN BLOCK LETTERS
Numéro de membre
registration number
Date
Disclosure regarding affiliation to other Native organization
Name : ___________________________________________
(Capital letters)
Are you a member of another native organization or association in Quebec?
Yes
No
Are you a member of another native organization or association outside of Quebec?
Yes
No
•
If yes, which one? : _____________________________________________________________________
•
If no, please sign the following declaration :
I __________________________ solemnly declare, that I am not a member of any other native organization or
(your name)
association in Quebec or elsewhere.
Signature : _______________________________________
Date : ________________________
Social economical
File No.
Education
What is your education Level ? :
Elementary school
Secondary school
University
Other : ______________________________________________
? Would you like to continue or complete your education ? :
Yes
No
If ‘’yes’’, please specify your field of interest?
Obtain high school diploma
Obtain college diploma
Computer studies
Health
Legal studies
Other (please specify) : ______________________________________________
Do you have specific training needs or requirements?
Yes
No
Employement
Are you presently employed?
Yes
No
If‘ ”yes”, please specify your current employment :
Forestier
Mining
Industrial
Office
Student
Medical
other (please specify) : ______________________________________________
Is there more than one income in your household?
Yes
No
In what salary range would your household identify with?
between $5,000 and $10,000 gross per year
between $11,000 and $15,000 gross per year
between $16,000 and $20,000 gross per year
between $21.000 and $25,000 gross per year
between $26,000 and $30,000 gross per year
between $31,000 and $35,000 gross per year
between $36,000 and $40,000 gross per year
$40,000 and over clear yearly
What is your primary source of income?
Full time employment
Part time employment
Seasonal
Self employed
Social assistance
Investment revenues
Other : ______________________________________
Housing
? Do you currently own your home?
Yes
No
If ‘’yes’’ how long have you owned your home?
__________________ year(s)
Describe the current condition of your home:
Good
Medium
Poor
Is your home in need of renovations?
Yes
No
Do you own any rental properties (rooming houses etc)?
Yes
No
Are you a tenant?
Yes
No
If yes, what percentage of your monthly income is designated for your rent?
0 à 10 %
10 à 20 %
21 à 30 %
31 à 40 %
41 and more
Do you require aboriginal housing?
Yes
No
Do you have a physical disability which requires specific alterations to your home?
Yes
No
Health
In your opinion describe your health as being:
Good
Acceptable
Poor
Do you suffer from any particular disease or illness?
Diabetes
Cardio
Other
Do you have any disabilities?
Yes
No
Do you think there is a need for treatment programs for drug /alcohol and/or gambling? (Lottery-video, cards etc.)
Yes
No
Do you believe in the healing properties of plants and herbal medicines?
Yes
No
Traditionals activities
Do you practice hunting, fishing or trapping?
Yes
No
If ‘’yes”, which do you practice?
Deer
Moose
Bear
Partridge
Gees
Duck
Caribou
If ‘”yes”, for what purpose
Ancestral and/or survival reasons
Sport
Other : __________________________________
Spirituality and culture
Do you practice the spirituality and culture of your ancestors?
Yes
No
Would you like to know more about the culture and traditional spiritual beliefs of your ancestors?
Yes
No