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