New Member
Fill out this form to become a member. This online enrollment should be completed only by individuals who can legally document their Chitimacha ancestry. Must be 21 years of age to complete this form
Email address *
First Name *
Your answer
Middle Initial *
Your answer
Last Name *
Your answer
Maiden Name *
Your answer
Chitimacha Descendants (List 4-5 Generations) *
Your answer
Phone Number *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
ZIP Code *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Are you state or federally recognized by an Indian tribe? *
If yes, which tribe? (N/A if no) *
Your answer
The information provided may be included in federal litigation. The code section criminalizing false statements to the federal government can be found under 18 U. S. C. §1001. To ensure the validity of the information collected, please check to confirm the following statement: *
Required
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Department of Design.