Applicant’s Acknowledgement and Consent I, ____________________________, the undersigned hereby represent and warrant that I am duly authorized to submit this application and provide information on behalf of any other party mentioned herein. I swear that the information submitted in this application is true, correct and complete to the best of my knowledge. I hereby authorize and instruct the Six Nations Elected Council, its agents, successors, and employees to obtain necessary information regarding this application from any source for the purpose of verifying the content of this application and deciding whether to grant permission for the above requested activity. If my request is approved, and the research permitted, I agree to accept all liability arising and resulting from the approved research. I further absolve Six Nations Elected Council, its agents, successors, and employees of any liability associated with, arising, or resulting from the approved research. I declare that I have read and understood the Policy for Conducting Ethical Research (SNCR GC#213/06/16/2009) and hereby certify that I have fully considered the ethical implications of the proposed research and believe that research will be conducted pursuant to applicable Six Nations, Provincial and Federal guidelines, policies, regulations and legislation. _______________________________ Signature _______________________ Date Supervisor Approval (if applicable) I, _______________________________ , the undersigned hereby represent and warrant that I am duly authorized to support this application. I certify that the protocol is complete and the research will be conducted in accordance with the Policy for Conducting Ethical Research and in an ethical manner. I swear that the applicant has obtained ethical research approval from the institution I represent prior to submitting this application for further ethics approval. I covenant that I will cooperate with the Six Nations Council Research Ethics Committee on all reasonable requests and furthermore that I will contribute meaningfully to any conflict resolution that may be required in the event research resulting from this application’s approval is reported as not in compliance with the Policy for Conducting Ethical Research. ______________________________ Signature of Applicant’s Supervisor (if applicable) ______________________ Date

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