UNITED CHEROKEE REPUBLIC OF NORTH AMERICA

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Cherokee Indians of North America

15374 W. County Line Rd., Republic, Missouri [65738] USA 980 Lakeview, Snellville, Georgia 11861 Cardinal Circle, Suite H, Garden Grove, CA 92843

APPLICATION FOR TRIBAL ENROLLMENT

(Follow directions completely. stamped envelope to address Return application along with Name:___________________________________ Full Birth Name:_____________________________________ Male:_____ Female: _______ 2. Indian, Maiden or other name by which you are known: ____________________________________ 3. Present address:____________________________________________________________________ (Street) (City) (County) (State) (Zip Code) 4. Telephone Number: __________________________ Social Security Number: _________________ 5. Date of Birth:_____________________ Place of Birth:___________________________________ 6. Physical Description: Height: _______ Weight: ______ Eye Color:_____ Hair Color: _____Blood Type: 7. Is your birth certificate on file with the Tribal Office? 8. Your degree of Cherokee Indian blood (if known)? ____ [ ] Yes [ ] No picture

Ever served in the military? ____ Branch:________

9. Give the name of the Cherokee Indian ancestor through whom eligibility for enrollment is claimed: Enrollment Number:____________________ Listed on which roll: ___________________
(NOTE: This person should have been considered a part of the historical tribe and you must prove lineal descent from yourself to this individual. Proof of relationship may be through birth and death certificates; obituaries; census records; Bible records; biographical sketches; probate records; etc; anything that shows relationship from one generation to another. Proofs must be submitted per each generation and will become a permanent part of the Cherokee Republic files. Photocopies are acceptable. You need not send originals.)

10. What is the relationship of the above individual to you? (self, parents, etc.) 11. Do you possess Indian blood of another tribe? 12. Name of other tribe, if yes? [ ] Yes [ ] No

Degree of other Indian blood? _______

13. Are you enrolled with another tribe? [ ] Yes [ ] No If yes, have you received benefits in land or money by virtue of such enrollment? [ ] Yes 14. If not Indian blood-line are considering adoption for yourself ?

[ ] No By who? David Jackson

FAMILY RECORD
15. Name of applicants spouse: _______________________________________________________________ 16. Applicants eligible children: ______________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ (A separate application MUST be filed for each child to become enrolled as a member of the tribe.) 17. Do you have a relative already enrolled in the Cherokee Republic? [ ] Yes [ ] No If so, whom? Enrollment #: ___________________________ Date of application: / / /

I, the undersigned, verify that all statements and the information provided with this application to be true and subject to penalties as stated in the Constitution and By-Laws of the Cherokee Republic. Signature of applicant: ___________________________________________________ ================================================================================== NON-REFUNDABLE APPLICATION FEE: $150.00 each $45.00 each child under 16 (Minor childs application must be signed by an adult). If done by other than the legal guardian, the individual must sign his/her name and then the applicants name.) Fees may be made by cashier check, money order, or personal check. Make payable to: Cherokee Republic/DAVID JACKSON, Elder ================================================================================= DO NOT WRITE BELOW THIS LINE - FOR OFFICE USE ONLY Date application received: / / Enrollment fee amount receiv Eldered : ____Check #_____

Application denied: Application accepted:

If denied, state reasons for denial: Roll Number:__________

Initials of Enrollment Committee members: _______________________________________________

Signature: ____________________________________ Official,

TRIBAL ANCESTRY CHART

INSTRUCTIONS FOR COMPLETING

LINEAGE CHART
Trace your ancestry on the family tree chart to your Cherokee Ancestor. Use full legal names. Your birth certificate, NOT birth registration, MUST be attached to this form; plus birth certificates, death certificates, and other documentation to establish a direct line to an ancestor alive in the last half of the 1800s. (Send copies of documents only!) Follow these instructions carefully. 1. On line #1, list your FULL name. ALWAYS use the maiden name when listing any FEMALES. 2. Fill in YOUR birth date; YOUR place of birth; YOUR marriage date; the PLACE of YOUR marriage. 3. Lines #2 and #3 are the parents of #1 on the Chart. On line #2, List your fathers FULL name. On line #3, list your mothers FULL MAIDEN NAME. 4. Fill in their birth date; place of birth; marriage date and place; and if deceased, their death date and place of death. 5. Lines #4 and #5 are the parents of #2 on the Chart. On line #4, list the father of your father; on line #5, list the mother of your father - their birth, marriage, and death dates and places. 6. Lines #6 and #7 are the parents of #3 on the Chart. On lines #6 and #7, list the parents of your mother - their birth, marriage, and death dates and places. 7. Complete the chart until you have filled in all lines or you have listed all the information you know. 8. If you are not sure of a name or date, fill in what you THINK it might be and place a question mark(?) behind it. 9. Fill in the lower left-hand lines, listing the necessary information on your ancestors who have roll numbers. If you have additional ancestors with roll numbers, list them on another sheet and attach that sheet to your application. 10. Remember to put your name in the lower right-hand corner on the Submitted by: line.

11. Be sure to return the application, lineage chart, documentation, selfaddressed stamped envelope, and your check or money order.

Abbreviation definitions: b. = date of birth p.b. = place of birth (county and state) m. = date of marriage (put place behind date) p.d. = place of death d. = date of death