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Cherokee Nation Seal CHEROKEE NATION
Registration Department
P.O. Box 948
Tahlequah, OK 74465
Intake Contact Sheet
CDIB Admendment Process
ADULTS: MUST SIGN OWN FORM IN "INK" AND PROVIDE A COPY OF IDENTIFICATION
MINORS: PARENT/AUTHORIZED AGENT/CUSTODIAN PARENT MAY REQUEST: ID REQUIRED
DUP CDIB:_____ DUP MEM:_____ ADD CHG:______ IPL:______ F&W:_______ AMEND:_________
(Name/DOB/BQ)
Current Address:
 
______________________________________________ _____________ __________ ____________
Mailing Address (Number, Street, Route, Box) City State ZIP
Name Change
(Was): ______________________________ (Now): ______________________________
******************** Name and Relationsip of Person Reporting Change: ********************
The applicant legally represented, such as a court appointed guardian, or court ordered custody, such as divorce custody? YES: _____ NO: _____
______________________________ This signature is by:
Signature of Requesting Person ( ) Person himself/herself
( ) Person making request: ______________
( ) Authorized Agent (Relationship)
Further Explanation: Attach a copy of your drivers license of ID card or your social security card with your signature. this is only for signature verification purpose.
________________________________________________________________________________
________________________________________________________________________________
G FORM C10(1/97) INTAKE CLERK:______________________________