NEW TRIBAL ENROLLMENT CARD REGISTRATION

Modoc Nation offers a variety of services to our members.

Full Name

Maiden Name

Date of Birth

Male Female

Mailing Address

Phone Number

Social Security Number

Citizenship #

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.

Please select one:

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

Date Signed

Printed Name of Signer

Signature of Adult Applicant or Signature of Parent/Guardian if applicant is under 18 years of age

By signing, applicant certifies that all information is true and correct to the best of their knowledge.

Preferred Delivery Method

1. Mailed to the address listed on the form 2. Pick up in person at 22 N. Eight Tribes Trail Miami, OK 74354.