New Tribal Enrollment Card Registration

New Tribal Enrollment Card Registration

Complete this form to register for a new Tribal Enrollment Card and provide the required photo, consent, signature, and delivery preference information.
Applicant Information
Full Name*

First NameMiddle NameLast Name
Maiden Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Mailing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Social Security #
Citizenship #
Photo Requirements and Consent
Photo Requirements:

•Photos are required for all adults 18 & older but are optional for minors
•Must be in color
•Taken within the last 6 months to reflect your current appearance
•Taken in front of a plain background
•Be solely of the applicant, no other people in view of the camera
•Taken in full-face view directly facing the camera
•Do not wear a hat or head covering that obscures the hair or hairline, unless worn daily for a religious purpose.
Likeness Permission*

Only use my likeness to produce this form of identification.I hereby grant permission to Modoc Nation to use my likeness to produce this form of identification AND in publications, news releases, online, and in other communications related to the mission of Modoc Nation.
Photo*

Cancelof
Signature and Delivery
Date Signed*

MonthDayYear
Date
Printed Name of Signer*

First NameLast Name
Signature
Preferred Delivery Method*

Mailed to the address listed on the formPick up in person at 22 N. Eight Tribes Trail Miami, OK 74354.
Should be Empty:

New Tribal Enrollment Card Registration

Applicant Information

Photo Requirements and Consent

Signature and Delivery