Witset Community Household Update

*for those living on reserve only 

First Name:

Last Name:

Clan:

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Home Phone:

Mobile Phone:

Email Address:

Spouse information

First Name:

Last Name:

Clan:

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Check if not applicable

Mobile Phone:

Email Address:

House Number:

Street  Name:

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Mailing Address:

(if different from residential address)

Are you and/or your spouse? 

Choose your means of communication: (for notification of events within our community)

Is your home wired in to get Highspeed Internet?

If not, are you interested in this for your home?

Do you have pet dogs in your household, if yes how many? 

# of dogs:

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Occupant Information

Check if no other occupants reside in the home

Name:

Age:

Name:

Age:

Name:

Age:

Name:

Age:

Name:

Age:

Name:

Age:

Clan:

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Clan:

Clan:

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Clan:

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Clan:

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Clan:

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Name:

Age:

Clan:

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Name:

Age:

Clan:

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Name:

Age:

Clan:

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Name:

Age:

Clan:

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# of Elders: 

(55 and up)

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# of Adults: 

(19 to 54)

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# of Children: (18 and under)

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VEHICLE(S):

# of Trucks:

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# of Cars:

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# of Vans/SUV:

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# not working vehicles

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Questions/Concerns or Comments:

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#3 - 205 Beaver Rd. Witset, BC V0J 2N1 • 250 847 2133 • Fax: 250 847 9291