Last Name, First, Middle, Maiden

___________________ ___________ ____________ ______

Mailing Address(# Street,route,box), City, State, Zip

Are you a registered member of any other tribe? Yes, No Tribe:___________

Have you registered with Cherokee Nation before?Yes, No

When?___________ Registration Number?___________

Please attach a "COPY" of the Certificate pf Degree On Indian Blood(CDIB) Card to the application. NO MEMBERSHIP CARD WILL BE ISSUED UNTIL CERTIFICATION IS AVAILABLE FROM THE BIA.

___Adair ___Muskogee ___Wagoner

___Cherokee ___Nowata ___Washington

___Craig ___Ottowa ___All Other Oklahoma

___Delaware ___Rogers ___Out of State

___Mayes ___Sequoyah ___Out of County

___McIntosh ___Tulsa

_________________________ __________________________

Date of Signature , Signature of Application(IN INK)

_______________________________________________________

CHEROKEE REGISTRY NUMBER________________________

REASON:________________________________________________ _______________________________________________________ _______________________________________________________

REG FORM-MI(3/91)__________________ _________________