I ­­­­­______________________________ am applying for membership in the Shasta Indian Nation and give my  permission and authorize the enrollment and eligibility committee to examine all records and documents, including roll books Found in the Bureau of Indian Affairs office, for the purpose of determining Shasta lineage and development of the rolls of the Shasta Indian Nation.

 In addition, permission is given to take and hold copies of information and documents pertaining to the development of your genealogy and degree of Shasta blood quantum.

 __________________________________                         ___________________________________
            Telephone number                                                                            Signature or Guardian 

 __________________________________                         ___________________________________
            Cellular number                                                                                Minors Signature                                                                                                                                                

__________________________________                          ___________________________________
            Email address                                                                                  Print Full Name         

__________________________________                          ___________________________________
                                                                                                                     Date                

                                                                                              ___________________________________
                                                                                                                    Home address

                                                                                               ___________________________________
                                                                                                                    City    State     Zip

OTHER NAMES FROM YOUR                                   YOUR OCCUPATION, HOBBIES, AND
FAMILY TREE                                                               SPECIAL INTERESTS

 _________________________________                       ______________________________________

_________________________________                       ______________________________________

_________________________________                       ______________________________________

           RETURN FORMS TO BILL EDWARDS   445 INGERSOLL, COOS BAY OR. 97420