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* Last Name:

* Address (or PO Box):

* City/Community:

* Province/Territory:

* Postal Code:

* Phone Number (preferred):

Phone Number (work):

Phone Number (cell):

* E-mail Address:

* Are you Inuit?
YesNo

* Have you lived in Manitoba for over 3 months?
YesNo

* Are you 16 or older?
YesNo

* What is your birth date (mm/dd/yyyy)?

Talents:
Drum Dancing
Throat Singing
Carving

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If you are associated with an Inuit Land Claim region, please check off the appropriate Inuit Land Claim region:
Inuvialuit Region
Nunavut Region
Nunavik Region
Nunatsiavut

* Do you wish to be contacted to run for the board of MIA?
YesNo

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