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T-1, r. 1 - Regulation respecting the application of the Fuel Tax Act

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SCHEDULE II
(s. 10.2R2)
I, the undersigned, certify that I am an Indian and that the fuel described on the invoices submitted with this application was purchased for my own consumption.
Name: ______________________________________________________________________________
(in block letters)
Address: ____________________________________________________________________________
(in block letters)
Date: _______________________________________________________________________________
Signature: ___________________________________________________________________________
O.C. 1876-87, s. 2; O.C. 1116-2007, s. 9.
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