INSTRUCTION SHEET

ENROLLMENT APPLICATION:
1. Answer all questions on the application. Your application will be returned if it is incomplete.

REQUIRED SUPPORTING DOCUMENTS:
1. STATE CERTIFIED BIRTH CERTIFICATE: The applicant’s birth certificate must be submitted to the Enrollment Office. An original CERTIFIED BIRTH CERTIFICATE from your local County Health District Office is the only birth certificate that will be accepted for enrollment purposes. You can secure the birth certificate at your local Health District Office or State Vital Statistics Office. (HOSPITAL BIRTH RECORDS OR STATEMENTS ARE NOT ACCEPTED FOR ENROLLMENT PURPOSES.) Also note that some counties will issue an abstract copy (computer generated) automatically. We DO NOT accept abstract copies. We require a certificate that shows a parent’s signature. Please send the original. We will make a copy and return it to you.

2. PROOF OF PATERNITY / MATERNITY
Original County or State Certified Birth Certificate: Signed by biological Parents
Biological Parents were married at time of birth: Marriage Certificate
Court Order stating who biological parents are: Court records / Child Support
Paternity / Maternity Statement: Notarized Statements by Father / Mother
DNA Test: Test Results for Father and/or Mother

Note: The Enrollment Application will not be processed through the Enrollment Office until ALL supporting documents are fully completed and received.

Please print out this as a hard copy, fill in the requested information about yourself and/or your family and return it by mail or contact us to send you an application.
PLEASE PRINT AND FILL OUT AS COMPLETELY AS POSSIBLE (ONE APPLICATION PER PERSON).

Date of Application: _____________________________________________________________

Name of Applicant:______________________________________________________________
(LAST) (FIRST) (MIDDLE)

Maiden or Other Names You Are Known By: _________________________________________

Current Mailing Address:_________________________________________________________
Mailing address City State Zip Code

Current Residence Address:_______________________________________________________
Residence Address City State Zip Code

Current Phone Number: (_____)_______________Alternative Number: (______)____________

Sex: M / F Social Security #_______________________________

Email Address: _________________________________________________________________

Date of Birth: ___________________Place of Birth:___________________________________

Is / Was the Applicant Adopted? Yes / No If Yes, Place of Adoption?____________________

If Yes, What name Did the Applicant Apply Under? ____________________________________


If you do not have a parent on the roll and are applying for membership under extraordinary circumstances, please indicate the ancestor through whom enrollment rights are claimed.

Name:__________________________________________ Allotment #:______________________

Relationship to the Applicant:________________________________________________________

Applicant’s Total Indian Blood Degree Claimed: _________________

Tribe ________________ Degree ___________ Tribe _________________ Degree__________

Tribe ________________ Degree ___________ Tribe _________________ Degree__________

Is the Applicant an Enrolled Member of Another Tribe? Yes / No

If Yes, What Tribe, Band or Rancheria? _____________________________________________

Mother’s Name: ________________________________________________________________
Last First Middle

Maiden or Other Names by Which Known: ___________________________________________

Current Mailing Address: _________________________________________________________
Mailing address City State Zip Code

Current Residence Address: ______________________________________________________
Residence address City State Zip Code

Current Phone Number: (_____)______________Alternative Number: (______)____________

Date of Birth: ________________Place of Birth:________________________________

Date of Death: _______________Place of Death:________________________________

Is Applicant’s Mother an Enrolled Tribal Member? Yes / No

Father’s Name: _________________________________________________________________
Last First Middle

Other Names by Which Known:____________________________________________________

Current Mailing Address: _________________________________________________________
Mailing address City State Zip Code

Current Residence Address: _______________________________________________________
Residence address City State Zip Code

Current Phone Number: (_____)_______________Alternative Number: (______)____________

Date of Birth: ________________Place of Birth:________________________________

Date of Death: _______________Place of Death:________________________________

Is Applicant’s Father an Enrolled Tribal Member? Yes / No


Guardian’s Name: ______________________________________________________________
Last First Middle

Current Mailing Address: _________________________________________________________
Mailing address City State Zip Code

Current Residence Address: _______________________________________________________
Residence address City State Zip Code

Date Appointed As Guardian: _____________ Current Phone Number: ( )________________

Name of Court: _________________________________________________________________
City County State


All birth certificates and court orders must be original certified copies from the county or state issuing the document. No abstract or photocopies will be accepted. Maternity/Paternity statements may be required.



To become a full member, you are required to be Native American. If you are not Native American, you can become an Associate Member of the ICBCCI. Once you become a member, and your name has been added to the tribe index, it cannot be removed, even if you have been banished from the tribe under the law of banishment. You are subject to the laws of this Tribe and the United States Government. These records are part of the Index File with the B.I.A. in Washington, D.C. A copy of the registration and financial information may be obtained from the Division of Consumer Services by calling (1-800-HELPFUL) REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL OR RECOMMENDATION BY THE STATE OF FLORIDA. BY SIGNING THIS APPLICATION YOU ARE CERTIFYING THAT ALL STATEMENTS ARE TRUTHFUL, FAILURE TO DO SO WILL BE CONSIDERED PERJURY AND PUNISHABLE BY PROSECUTION. MEMBERSHIP IS FREE OF CHARGE



APPLICANT SIGNATURE: ___________________________________________________

DATE __________________________________