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REQUEST FOR CHANGE OF INFORMATION
PLEASE CIRCLE APPLICABLE CHANGE(S)
DEPENDENT SPOUSE: I do verify that I am not in receipt of Social Assistance, Employment Insurance, or Disability Payments. I hereby give consent for authorization of any searches through various agencies.
Full Name: Current School:
Name of Course: Course Number:
New Address:
Phone Number:(If new)
Effective:DAY MONTH YYYY
Effective:DAY MONTH YYYY
Birth date:DAY MONTH YYYY
Birth Date:DAY MONTH YYYY
Full Name(Of Dependent)
Spouse SIN:
Treaty #:
(If a newborn - attach a copy of the birth certificate)
Band:
Spouses’ Name (Print) Spouses’ Signature:
“As long as the sun shines, the river flows and the grass grows...”
ADD DEPENDENT
Full Name(Of Dependent)
REMOVE DEPENDENT
WITHDRAW FROM A COURSE
Name of Program:
WITHDRAW FROM A PROGRAM
Date:
DAY MONTH YEAR
Signature
Program Manager Signature Date:
DAY MONTH YEAR
Post SecondaryEducation
LONG PLAIN FIRST NATIONTREATY ONE 287(35)POST SECONDARY DEPARTMENT
LONG PLAIN FIRST NATION110-5010 Crescent Road West, MB R1N 4B1
Phone: (204) 857-7474
Fax: (204) 857-7480Email: [email protected]: www.lpet.ca
Phoned-In Emailed
