Fill in all blanks. Type or print (legibly) all information. (Make as many copies of this form as you need.) A cheque or money order for $10.00 (Cdn. Funds) must accompany each application.

  1. Applicant’s Name
Name as it is to appear on certificate
Street address
City/town, state, postal/zip code
  1. Name of Ancestor (as it is to appear on the certificate.)
Name of qualifying ancestor who was on Manitoulin 100 years prior to date of application
Birth (date) (place) Death (date) (place)
Baptism (date) (place) Buried (date)  (place)
Marriage (date) (place)
Spouse (name – maiden where applicable)
Birth (date) (place) Death (date) (place)
Where on Manitoulin did the ancestor settle? (Provide town, city, village, township, district as known.)
Emigrated from (if known) (Provide town/township, county, state, province or country, as known.)
Proof of travel on Manitoulin prior to date of application. (Please use separate sheet if you need more space)


  1. Complete Pedigree chart and return it with this application. 
  2. Information as you wish it to appear on the Centennial Settler Certificate.You must complete this form EXACTLY as you want the certificate to read. If it is not completed accurately, it may cause errors and/or delays in your order.
This is to certify that:
is a descendant of:
who settled on Manitoulin 100 years prior to date of application
  1. Release. 
I release all information included in my application to the potential and future publishing efforts of the Manitoulin Genealogy Club.
For MGC Use Only
File Number
Name (ancestor)
Date Returned (for further data)
Date Certificate Issued

Please Note: The application for this certificate requires the completion of a pedigree form.