Chickamauga Cherokee Indian Creek Band Inc.
Membership Application |
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Applicant Information |
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| Name: |
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| Date of birth: |
SSN: |
Phone: |
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| Current address: |
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| City: |
State: |
ZIP Code: |
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| Own Rent
(Please circle) |
Monthly payment or
rent: |
How long? |
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Please Provide folowing Information |
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| Are You an Enrolled
Member of a State or Federally Recognized Tribe? |
Y__________ N ________ |
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| If Yes |
How Long |
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| Are You of Native American
Descent? |
Y___________ N ________ |
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| If Yes Please Provide
Name of Tribe. |
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Emergency Contact |
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| Name of a relative
not residing with you: |
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| Address: |
Phone: |
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| City: |
State: |
ZIP Code: |
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| Relationship: |
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Spouse Information if joint
membership |
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| Name: |
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| Date of birth: |
SSN: |
Phone: |
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Children if membership privileges
desired |
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| Name |
Birth Date: |
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| Name |
Birth Date: |
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| Name |
Birth Date: |
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| Name |
Birth Date: |
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| Name |
Birth Date: |
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Signatures |
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| I authorize the verification
of the information provided on this form. I have received a copy of
this application. |
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| Signature of applicant: |
Date: |
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