"Request Form for Confidential Information - White Earth Reservation Tribal Council Tribal Enrollments" - Minnesota

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White Earth Reservation Tribal Council Tribal Enrollments
REQUEST FOR CONFIDENTIAL INFORMATION
P.O. Box 506
Phone: (218) 983-3285
White Earth, Minnesota 56591
Fax:
(218) 983-3707
REQUEST FOR:
[ ] Indian Preference BIA Form 4432
[ ] Certificate of Degree of Indian Blood (CDIB)
[ ] Tribal Enrollment Card
[ ] Other (explain): ___________________________________________________________________
** NOTE: For proof of decendency, please use the Request for Verification of Decendency Form
IDENTIFICATION:
Name: ______________________________________________________________________________
(First)
(Middle)
(Maiden)
(Last)
DOB: _____________________________
(Month)
(Day)
(Year)
Current Mailing Address:
____________________________________________________________________________________
(Address)
(City)
(State)
(Zip)
** NOTE:
This address will be used to update your Enrollment record if it is different than what we have on file
Telephone Number: ____________________________________________
If request is for a minor, proof of legal guardianship must be included such as certified birth certificate
along with documentation of any name change(s):
Relationship: ______________________________
Print Name of Requestor: ________________________________________________________________
Signature: __________________________________________________
Date: ____________________________________
White Earth Reservation Tribal Council Tribal Enrollments
REQUEST FOR CONFIDENTIAL INFORMATION
P.O. Box 506
Phone: (218) 983-3285
White Earth, Minnesota 56591
Fax:
(218) 983-3707
REQUEST FOR:
[ ] Indian Preference BIA Form 4432
[ ] Certificate of Degree of Indian Blood (CDIB)
[ ] Tribal Enrollment Card
[ ] Other (explain): ___________________________________________________________________
** NOTE: For proof of decendency, please use the Request for Verification of Decendency Form
IDENTIFICATION:
Name: ______________________________________________________________________________
(First)
(Middle)
(Maiden)
(Last)
DOB: _____________________________
(Month)
(Day)
(Year)
Current Mailing Address:
____________________________________________________________________________________
(Address)
(City)
(State)
(Zip)
** NOTE:
This address will be used to update your Enrollment record if it is different than what we have on file
Telephone Number: ____________________________________________
If request is for a minor, proof of legal guardianship must be included such as certified birth certificate
along with documentation of any name change(s):
Relationship: ______________________________
Print Name of Requestor: ________________________________________________________________
Signature: __________________________________________________
Date: ____________________________________
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