Erie Indian Moundbuilders Tribal Nation

The Erie Indian Moundbuilders Tribal Nation
Tecumseh Brown-Eagle , Chief/Chairman

P.O. Box 473, Erie, PA 16512-0473
Phone: 814-572-4137 Toll Free Fax: 1-877-822-6285
tecumseh@eriemoundbuilders.com

ENROLLMENT APPLICATION

ATTENTION: We reserve the right to restrict membership to anyone per The United Nations Draft Declaration on the Rights of Indigenous People.

PART I: Please complete the entire application.

FULL NAME: _________________________________________________________________________________________________
Other names used (Maiden, Native American Name, etc): ______________________________________________________
Mailing Address: ____________________________________________________________________________________________
City: ___________________________________________________ State: ___________ Zip Code: _______________________
Telephone #: _____________________________ Social Security #: ____________________________ (required for ID card)
Sex: Male: __________ Female: __________ Date of Birth: _____________________________________(month/date/year)
PART II: Include persons full name.  Tribal placement is determined by ancestral place of birth and name.
Birthplace: _______________________________ Mother: ________________________ Father: __________________________
Maternal: Grandmother: __________________________________ Grandfather: ______________________________________
Paternal: Grandmother: __________________________________ Grandfather: ______________________________________
Application filed by: Parent: __________ Child: __________ Sponsor: __________ Self: __________
Please indicate: Natural: __________ Adopted child: __________
Name of Person Filing Application: ______________________________________
Mailing Address: _____________________________________________________
City ________________________________State___________Zip Code:________
Relationship to Applicant: _____________________________________________
NOTICE OF FALSE OR MISLEADING INFORMATION : If any statements are proven to be misleading or false,  penalties may include: delay, expiration, criminal or civil charges filed against provider.
PRIVACY ACT NOTIFICATION : Any enrollment information will remain confidential.
* Natural Law Copyright
** Erie Indian Moundbuilders Tribal Nation registration requires approval of Tribal Chairman.
I hereby certify that the statements given for the purpose of Eire Indian Moundbuilders Tribal nation enrollment are correct and true.

Signature: _______________________________________________________________ Date: ____________________________

Notary or Tribal Councilor: _________________________________________________ Date: ____________________________

                                               Copyright © 2005-2009 Erie Indian Moundbuilders Tribal Nation. All Rights Reserved.
                                               tecumseh@eriemoundbuilders.com