P. O. Box 1301
Bethel, AK. 99559
Ph: (907) 543-2887 (Bethel Office) / (907) 222-5058 (Napaimute Office)
(907) 545-2877 (Cell)
Email: napaimute@gci.net
Website: www.napaimute.org
Application No. ______ Date Received ______
NATIVE VILLAGE OF NAPAIMUTE
TRIBAL ENROLLMENT FORM
Applicant’s full name: _____________________________________________________
Native, maiden or other names by which known: ________________________________
Mailing Address: _________________________________________________________
_________________________________________________________
City State Zip Code
_______________________________ ______/______/______ ________________
Place of Birth Date of Birth Social Security No.
Regional Corporation: __________________ Village Corporation: _________________
DEGREE OF NATIVE BLOOD CLAIMED:
Native___________________ Total Native Blood_____________ Tribe ____________
Is either parent enrolled as a member of another tribe? YES NO
If Yes, which parent and with what tribe? ______________________________________
Is applicant an adopted child? YES NO
Is applicant enrolled with another tribe? YES NO
If Yes, what tribe? ______________________________________
Is applicant a direct lineal descendent of a member of the tribe? YES NO
(updated 3/9/02)
Native Village of Napaimute – Tribal Enrollment (Continued)
Dependents Under l8 Years of Age Living in Your Home:
FULL NAME AGE BIRTHDATE % NATIVE SOCIAL SEC. No.
BLOOD
_____________________________ ____ ___/___/___ _____ ______________
_____________________________ ____ ___/___/___ _____ ______________
_____________________________ ____ ___/___/___ _____ ______________
_____________________________ ____ ___/___/___ _____ ______________
_____________________________ ____ ___/___/___ _____ ______________
_____________________________ ____ ___/___/___ _____ ______________
COPY OF BIRTH CERTIFICATE, BAPTISMAL RECORD, OR OTHER PROOF OF BIRTH AND PARENTAGE MUST BE SUBMITTED WITH APPLICATION FORM
______________________ ________________________________________________
Date signed Signature of adult applicant or sponsor
If sponsored, relationship to applicant:_________________________________________
ACTION BY COUNCIL: Approved ( ) Reject ( )
Reason Rejected: _________________________________________________________
Vote: FOR _______ AGAINST _______
Date of Meeting _______________ _________________________________________
Signature of President of Council
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*FOR OFFICE USE ONLY*
( ) New Enrollee ( ) Update ( ) Non-Member ( ) Approved ( ) Disapproved
Voter Status ( ) Yes ( ) No Date of Death _____/_____/_____