DECLARATION OF REPRESENTATION

A1

By Honouring Our Past

DECLARATION OF We Determine Our Future
REPRESENTATION
We are the Kichesipirini, the proud People of the Island, rulers of the river, since time immemorial.
We are the Original People of this region and we have maintained our attachment to our territory. We
acknowledge that our natural resources are a gift from the Creator.
As the Original People we have inherent rights and obligations in relation to this region, our territory.
We have survived great hardship and adversity, only to become stronger.
We are committed to actively protecting our heritage and developing our shared future.
DECLARATION OF REPRESENTATION
I, ____________________________________ do hereby declare that I am of Algonquin\Nipissing
descent. My ancestry traces from ____________________________________________________.

My children under the age of 18 are as follows-

Name ___________________________________ Birth date __________
Name ___________________________________ Birth date __________
Name ___________________________________ Birth date __________
Name ___________________________________ Birth date __________

My spouse is _________________________________

For the purposes of identifying as a Person of Algonquin ancestry, let it be known that I, and members
of my household, as named here, have been accepted and are now represented by:

The Kichesipirini Algonquin First Nation.

Name:
Street Address:
City: Province: Postal Code:
Phone: E-mail: Fax:
Language:

Algonquin: Enrolled: Entitled: Status: Y N

Nipissing: Enrolled: Entitled: Status: Y N
ID Number: Card Number:
ANTC Number:

Staff Verification:

STAMP

2005
The Kichesipirini Algonquin First Nation

I,__________________________________________, do declare that having read all official

documents associated with The Kichesipirini Algonquin First Nation that I do understand and am in
agreement with the principles and objectives of the Constitution, Articles and By-Laws, Charter,
Freedoms and Obligations, and Codes of Conduct of The Kichesipirini Algonquin First Nation. I
understand that I have a responsibility to remain informed and actively involved in my chosen
Aboriginal Nation and do act as an Ambassador for my People. It is my further obligation as a proud
citizen of The Kichesipirini Algonquin First Nation to learn and promote the traditional community
values of
I have an important role to honour my ancestors of the past and consider the generations of the future.

Signature:_______________________________________________ Date:_________________________

Documentation Presented
Marriage: Birth: Baptismal:
Genealogy: Other:
Programs / Services Accessed
Health: Hunting / Fishing: Housing:
Employment / Training: Family History: Information:

Official Representative:_____________________________________ Date:________________________

This form supersedes any representation form that may have been previously signed.

All required supporting documentation has been provided and is being maintained agreeable to terms meeting my
satisfaction and according to governing legislation. I understand that those documents cannot be shared or accessed
by anyone outside of these terms without my expressed written permission.

This form is for the sole use of Entitled, Enrolled, or Status Algonquins and does not constitute the sole basis of
citizenship within
The Kichesipirini Algonquin First Nation.
Please refer to The Kichesipirini Algonquin First Nation Constitution and Citizenship Code for further details.

The Kichesipirini Algonquin First Nation

c/o Paula LaPierre
244 Welland St.
Pembroke Ont.
K8a 5y4
(613) 735-3616
kichesippi@hotmail.com

Date Initial

Migwetch