Western University

Declaration of Indigenous Citizenship or Membership

Last Name or Surname:

First Name or Given Name:

Western Employee ID (if applicable):

Email:

Reason for Affirmation:
Please specify the purpose for which you are declaring Indigenous citizenship or membership. Be sure to select the opportunity and or opportunities you are being considered for.

Staff

Faculty

Elder

Knowledge Keeper

Other:

I understand that the initiative for which I am being considered is intended specifically for an Indigenous individual, or I have applied to an open role or initiative and have declared or claimed Indigenous citizenship or membership in order to be given preference. As such, I solemnly declare that I hold Indigenous citizenship or membership as demonstrated by the submission of the following:

My detailed statement of relational positionality¹, which includes a demonstration of lived experience² and includes details about my lineal descent³ as per guidance provided in the University's Procedure for Policy 1.58 - Affirming Declarations of Indigenous Citizenship or Membership; and
My proof of citizenship or membership to the Indigenous Nation claiming me, as per the Procedure for Policy 1.58 - Affirming Declarations of Indigenous Citizenship or Membership.

I understand that for Indigenous-designated positions or initiatives and those where Indigenous citizenship or membership is preferred, should my claim of Indigenous citizenship or membership not be affirmed, and not successfully appealed, my application will be rejected and my candidacy terminated.

I further understand that providing false or misleading information about Indigenous citizenship or membership may result in an investigation led by Western University and, if the concerns are well founded, corrective action may be taken, including the termination/revocation of any appointment/role, opportunity, fellowship, bursary, scholarship, award and/or relevant Indigenous-designated/preferred initiative and/or that I may be subject to disciplinary or other proceedings under applicable University policy/collective agreement.

Next Steps - Affirming Declarations of Indigenous Citizenship or Membership

Please upload these three required documents below:

A detailed statement of relational positionality¹, which includes a demonstration of lived experience² and details outlining my lineal descent³

Choose a file:
Two documents demonstrating proof of citizenship or membership to the Indigenous Nation claiming me

Document #1: Document #2:
Note: Allowed maximum size for each file is 10Mb
Allowed file types: jpg,jpeg,png,gif,pdf,doc,docx

If you have circumstances that prevent you from providing the requisite documentation, please send an email message requesting assistance to indigenous.affirmation@uwo.ca.

By clicking on this box, I hereby certify that all statements are complete and correct. I understand that if I make an intentionally false declaration of Indigenous citizenship or membership, I will not be eligible to apply for any future roles (i.e., any non-Indigenous designated role) at Western University.

To verify that you are a human, please enter the text below:

For more information, contact:

Office of Indigenous Initiatives
Western Student Services Building, Room 2150
1151 Richmond Street, London, ON N6A 3K7
Email: indigenous.affirmation@uwo.ca
Website: https://indigenous.uwo.ca

¹ Positionality refers to how differences in social position and power shape identities and access in society ( https://indigenousinitiatives.ctlt.ubc.ca/classroom-climate/positionality-and-intersectionality/).

² Lived experience is the "personal knowledge about the world gained through direct, first-hand involvement in everyday events rather than through representations constructed by other people. It may also refer to knowledge of people gained from direct face-to-face interaction rather than through a technological medium" (https://www.oxfordreference.com/).

³ The term lineal consanguinity describes blood relationships where one person is a direct descendant or ascendant of another, meaning they are related in a straight-line family connection like a parent-child or grandfather-grandchild (https://www.law.cornell.edu/wex/lineal_consanguinity#:~:text=Lineal%20consanguinity%20is%20the%20blood,father).

The personal information on this form is collected under the authority of The University of Western Ontario Act 1982, as amended. To view the complete Personal Information Collection Notice, visit the online Academic Calendar at: http://www.westerncalendar.uwo.ca