1. FAMILY NAME: _________________________________
last name
NAME:_________________________________________ Office use only
first middle
2. MAILING ADDRESS:
______________________________________________
street/Apt No.
______________________________________________
city state zip
3. SEX M F
4. PLACE OF BIRTH: _____________________________
city/county
5. DATE OF BIRTH: ____/_____/_____
6. BIRTH NUMBER: ________________
birth reg. no.
7. HEIGHT: ______ 8. WEIGHT: _____
9. HAIR:_____ 10. EYES:_______
11. HOME PHONE: (____)______-_______
12. OCCUPATION: _________________________________
13. PERMANENT ADDRESS:___________________________
_____________________________________________
_____________________________________________
14. FATHER'S NAME: ______________________________
BIRTHPLACE: _________________________________
BIRTH DATE: _____/_____/________
OKLEVUEHA CITIZEN Y N
OTHER TRIBE Y N
TRIBE:_______________________________
15. MOTHER'S NAME: ______________________________
BIRTHPLACE: _________________________________
BIRTH DATE: _____/_____/________
OKLEVUEHA CITIZEN Y N
OTHER TRIBE Y N
TRIBE:_______________________________
16. HAVE YOU EVER BEEN MARRIED? Y N
IF YES, GIVE DATE:_______
WIDOWED: Y N DIVORCED: Y N
IF YES, GIVE DATE:_______
17, DO YOU HAVE CHILDREN? Y N
NAME:_____________________________ DOB:______
NAME:_____________________________ DOB:______
NAME:_____________________________ DOB:______
NAME:_____________________________ DOB:______
NAME:_____________________________ DOB:______
NAME:_____________________________ DOB:______
18. ARE YOU NOW SERVING OR HAVE YOU
EVER SERVED IN THE UNIFORMED
SERVICES OF THE UNITED STATES?
IF SO INDICATE YOUR STATUS
19. DO NOT SIGN UNTIL REQUESTED TO DO SO BY PERSON ADMINISTERING OATH.
The following can adminster the OATH: Notory, Tribal Administrator
or US Postal Employee. Applicant must sign OATH and submit it with
the application (children excepted). Agents authorized to adminster the
OATH shall Stamp or Emboss the box numbered
[20]. False statements made knowingly and willfully shall disqualify the
applicant and render any future benefit or service VOID.
20. ===================================================================
READ and SIGN the membership requirements of the Oklevueha Band
Indian Colony lised on this form Failure to accept the terms as
specified shall disqualify you from consideration. You must sign
this application form in the presence of a Notory, Tribal Admin-
istrator or Postal Employee
===================================================================
Subscribed and sworn before me
_____/______/_____
date
_________________________
signature
S.E.A.L
===================================================================
Submit application with $25.00 FEE
NOTE: a seperate application is required of every prospective member.
Attach following supportive documents:
- Certified copy of Birth Record
- Official Copy of Tribal Roll # if enrolled in another tribe
- Statement by Tribal Elder of affiliation with Oklevueha
- Listing of Parents/Grandparents and Great Grandparents and
known Indian blood degree
=======================================================================
