Applicant's Date of Birth *

MM

DD

YYYY

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone / Cell *

(###)

###

####

Address of Business to be Licensed *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Individual in Charge at this Location *

First Name

Last Name

Have you Previously Had a Business License from this First Nation? *

Yes

No

Are you Presently Registered with a Federal Government or a Self Regulating Professional Body with Respect to the Conduct of Your Business? *

Yes

No

Is the Business Incorporated? *

Yes

No

Incorporations:

Federal

Provincial

Is the Business Administered by a Partnership? *

Yes

No

Location *

On-Reserve

Off-Reserve

By submitting this form, I certify that all information is accurate and I have permission to act on behalf of my organization. I give permission for the staff at SFNIBA to contact me about the informaiton in this form. *

I Agree

I Disagree