Application Enrollment Earth Form – Fill Out and Use This PDF

			White Earth Reservation Tribal Council
			Application for Enrollment
			Tribal Enrollments/Vital Statistics
				P.O. Box 506
			White Earth, Minnesota 56591
APPLICANT:
Name: ___________________________________________________________________________					DOB: _____________________________
(First)		(Middle)	(Maiden)	(Last)	(Month) (Day)	(Year)

Address: ______________________________________________________________________________________________________________

(P.O. Box or Physical Address)		(City)	(State)	(Zip)
*Place of Birth: __________________________________________________			SS No.: ______________--________--________________
(City)	(State)
Is the Applicant a member of another tribe? ________________		If yes, what Tribe? _______________________________________________

*If the applicant was born outside the United States, you must provide proof of citizenship <><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><>

MOTHER OF APPLICANT:

Name: ___________________________________________________________________________				DOB: _____________________________
(First)	(Middle)	(Maiden)	(Last)	(Month)	(Day)	(Year)

Address: ______________________________________________________________________________________________________________

(Current Mailing Address)	(City)	(State)	(Zip)
Place of Birth: _________________________________________________		SS No.: ______________--__________--______________
(City)	(State)

Is Mother an enrolled member of the Minnesota Chippewa Tribe? __________ If yes, What Reservation? ________________________________

Enrollment No.: ___________________________________________Blood Degree: ____________________________________

If no, is she a descendant of the Minnesota Chippewa Tribe? ________ * If yes, please attach a copy(s) of B.C. linking her to the enrolled member

Name of person descendant blood is derived from: _____________________________________________________________________________

Does mother possess any other Native American Indian Blood? _______________ From what tribe? ___________________________________

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FATHER OF APPLICANT:

Name: ___________________________________________________________________________			DOB: _____________________________
(First)	(Middle)	(Last)	(Month)	(Day)	(Year)

Address: ______________________________________________________________________________________________________________

(Current Mailing Address)	(City)	(State)	(Zip)
Place of Birth: ____________________________________________		SS No.: ________________--___________--_______________
(City)	(State)

Is Father an enrolled member of the Minnesota Chippewa Tribe? __________ If yes, What Reservation? ________________________________

Enrollment No.: ____________________________________________Blood Degree: _____________________________________

If no, is he a descendant of the Minnesota Chippewa Tribe? _______ * if yes, please attach a copy(s) of B.C.(s) linking him to the enrolled member

Name of person descendant blood is derived from: ____________________________________________________________________________

Does Father possess any other Native American Indian Blood? _______________ From what tribe? __________________________________

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Signature of Applicant or Legal Guardian (if a minor): __________________________________________________ Date: __________________________

(If legal guardian, please attach proof)

Relationship to Applicant:	______________________________________		Phone Number:	______________________________________
* SEE REVERSE SIDE FOR IMPORTANT INSTRUCTIONS

PRIVACY NOTICE:

The Minnesota Chippewa Tribe (MCT) and its Constituent Bands will use the information you provide to determine eligibility for enrollment with the MCT. Providing social security numbers is optional. If you do not provide other information, it may delay processing. In the event the application is approved, information about the applicant will be used to contact the applicant about the benefits of tribal membership. Information about members is used to update MCT and Band records.

INSTRUCTIONS: 1. Complete the entire first page of this application form.
2.	Attach a COPY of the applicant’s STATE CERTIFIED Birth
	Certificate. Also include if necessary, a copy of a name change document,
	Such as driver license, state ID card, marriage, divorce, or court order.			* HOSPITAL
	RECORDS AND BAPTISMAL RECORDS ARE UNACCEPTABLE
3.	Attach a copy of Proof of Citizenship, if born outside of the
	United States.
4.	If the applicant is a member of another tribe, a
	Relinquishment Form must be attached to the application.
5.	If one of the parents possesses MCT descendant blood, attach a copy of
	their birth certificate so that all MCT blood will be counted along with the
	enrolled parent.
6. FAXED APPLICATIONS WILL NOT BE ACCEPTED,
	ORIGINALS MUST BE MAILED TO THIS OFFICE.
NOTICE:	If the applicant’s parents are both MCT members but affiliated
	with different bands, the applicant will be enrolled under the
	mother’s reservation and band unless otherwise specified.

PLEASE CONTACT: WITH ANY QUESTIONS YOU HAVE REGARDING THE APPLICATION

White Earth Tribal Enrollments,

Phone: (218) 983-3285 or toll free 1-800-950-3248, ext. 5250 or 5251

OR

The Minnesota Chippewa Tribe – Tribal Operations,

Phone: (218) 335-8581 or toll free 1-888-322-7688

WARNING: A FALSE STATEMENT ON ANY PART OF THE APPLICATION MAY RESULT IN A DENIAL OR LOSS OF MEMBERSHIP.

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FOR OFFICE USE ONLY:

Father: _________________________________________________________________

ID No.: ____________________________ AR No.: ____________________________

Family No.: ________________________ Enrollment Date: ______/______/________

MCT BQ: _________________________ Band: ______________________________

Mother: ________________________________________________________________

ID No.: ____________________________ AR No.: ____________________________

Family No.: ________________________ Enrollment Date: ______/______/________

MCT BQ: _________________________ Band: ______________________________

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Applicant’s MCT BQ: ____________________ Band: ___________________