ICWA Committee Application
This is a voluntary 5-year position to be a member of the Native Village of Eyak Indian Child Welfare Act Committee. The
committee will meet once a month to discuss Alaska Native Children that are in the OCS system. Once a month you will
meet with the ICWA coordinator to go over cases that the Tribal council have intervened upon and any future cases that
the tribe is notified of Children who have entered the OCS system. The committee will hear the details of cases, be made
aware of all possible interventions on families and placement of children. The committee will also serve on the Child
Advocate program that handles child abuse, child neglect, and sexual assaults. Members must be able to listen to and
discuss sensitive details of case.
Personal Information
Name:
Last First
Middle
Telephone: Social Security Number Mailing Address:
Are you known by any other name?
Are you Alaska Native? Do you have a C.I.B?
If yes tribe of origin:
Are you a legally eligible for employment in the United States: Have you ever been
convicted of a felony?
If yes, identify the date of conviction, where the charges were determined, the
nature of the charge and case number.
Have you ever been convicted of a misdemeanor involving violence, minors under the
age of 18 or weapons?
This position is about children subject to the Indian Child Welfare Act, Indian Child
Protection and Family Violence Protection Act:
Have you ever been arrested or charged in connection with sexual abuse or
sexual assault of a minor or adult?
If yes, identify the date of conviction, where the charges were determined, the
nature of the charge and case number.
Have you ever been arrested or charged with Domestic Violence?
If yes, identify the date of conviction, where the charges were determined, the
nature of the charge and case number. ________
Education
High school: Address From: To
Did you graduate.
College Address
From: To Did You Graduate
Military Service
Branch: From To
Rank at Discharge: Type of Discharge:
If other than honorable explain:
References
Please List three professional references
Full Name:
Relationship:
Company:
Phone:
Address:
Full Name:
Relationship:
Company:
Phone:
Address:
Full Name: Relationship:
Company: Phone:
Address:
I certify the information provided on this application is
correct and accurate. I authorize Native Village of Eyak to investigate the information
provided and my background, including criminal.
Applicant Signature Date
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signature
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