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Fill Online, Printable, Fillable, Blank Incompleteapplicationscannotbesubmitted.Allapplicationsmaybesubjecttoasitevisit.AsofSeptember1,2019, allapplicationswillberequiredtopaya$100nonrefundableapplicationprocessingfee.Ifthebusinessiscertifi Form

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Incompleteapplicationscannotbesubmitted.Allapplicationsmaybesubjecttoasitevisit.AsofSeptember1,2019, allapplicationswillberequiredtopaya$100nonrefundableapplicationprocessingfee.Ifthebusinessiscertified, theyearonecertificationfeewillbewaived. PerPawneeNationofOklahomaLaw(Ordinance)No.9549;PawneeNationTribalEmploymentRightsAct,tobe Section03.(k)Indian/NativeAmericanmeansanymemberofafederallyrecognizedIndiantribe. Section03.(l)Indianownedfirmorentitymeansanycommercial,industrial,orotherbusiness,whichisowned byanIndianorIndians,orotherIndianownedfirmorentity,providedthatsuchIndianownershipconstitutesnot lessthanfiftyonepercent(51%)oftheenterprise. (Pawnee Nation)

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  • 31 other fields

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1
P.O.Box470881LittleDeeDrivePawnee,OK74058Phone:918‐762‐3621Fax:918‐762‐6446

Incompleteapplicationscannotbesubmitted.Allapplicationsmaybesubjecttoasitevisit.AsofSeptember1,2019,
allapplicationswillberequiredtopaya$100non‐refundableapplicationprocessingfee.Ifthebusinessiscertified,
theyearonecertificationfeewillbewaived.
PerPawneeNationofOklahomaLaw(Ordinance)No.95‐49;PawneeNationTribalEmploymentRightsAct,tobe
certifiedasan“Indian‐OwnedFirm”bythePawneeNationTEROOffice,yourbusinessmustmeetthesedefinitions:
Section03.(k)“Indian”/“NativeAmerican”meansanymemberofafederallyrecognizedIndiantribe.
Section03.(l)“Indianownedfirmorentity”meansanycommercial,industrial,orotherbusiness,whichisowned
byanIndianorIndians,orotherIndianownedfirmorentity,providedthatsuchIndianownershipconstitutesnot
lessthanfifty‐onepercent(51%)oftheenterprise.
1.FIRMIDENTIFICATION
DateofApplication______________________________________________
FederalIdentification/SocialSecurityNo.____________________________
______________________________________________________________
NameofBusiness

____________________________ _________________ _________________ ____________
MailingAddress City State Zip
TypeofBusiness:______SingleProprietor______Corporation_____LLC_____Partnership
PercentofIndianOwnership:_____________(Mustbe51%ormore)
____________________________________________ _______________________________________
ContactNameBusinessPhone
____________________________________________ _______________________________________
EmailBusinessFax
YearBusinesswasEstablished:_________No.ofEmployees_______No.ofNativeAmericans:_______
2
P.O.Box470881LittleDeeDrivePawnee,OK74058Phone:918‐762‐3621Fax:918‐762‐6446

2.CAPITAL&EQIPMENT
A.Capital:Identifyamountandsourceoforiginalandpresentcapital(i.e.,contributedby
owner,bankloan,orothertypeofloan).Ifloan,indicatenames(s)ofthoselegallybound
torepay.
B.Equipment:Listallequipmentpertainingtoday‐to‐dayoperationsandbusiness.
QuantityDescriptionPriceHowObtained
(BookValue)(Purchased,Donated,etc.)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
3
P.O.Box470881LittleDeeDrivePawnee,OK74058Phone:918‐762‐3621Fax:918‐762‐6446

DocumentationRequirements
I.Management
1.Provideforeachownerofmorethan5%interest,allseniormanagementpersonnelandmembersof
theBoardofDirectorthefollowing:
A.Name
B.Address
 C.SocialSecurityNumber
 D.IfIndian,TribalAffiliationandEnrollmentNumber
 E.Percentageofownership
2.Presentposition(descriptionofallduties)
3.Previousbusinessexperience
4.Previousworkexperienceinareasinwhichfirmintendstoengage
5.EducationandTraining
6.Otherjobspresentlyheld
7.ControlofCompany:
 A.Identifyname
 B.Race
C.Titleincompanythoseindividuals(ownersandnon‐owners)whoareresponsiblefor
daytodaymanagement,including,butnotlimitedto,thosewithprimeresponsibilityfor:
 a.Financialdecisions
 b.Managementdecisions,suchas:
•Marketing&Sales
•Hiring&Firing
•Purchaseofmajorequipment&supplies
•Supervisionoffieldpersonnel
8.Describeorattachanystockoptionsorotherownershipoptions that are outstanding, and any
agreementsbetweenowners&thirdparties,whichrestrictownershiporcontrolofIndianowners.
9.Aswornstatementoftheproperofficerindicating:
A.Thetotalnumberofshareofthecapitalstockactuallyissuedandtheamountofcash
paidintothetreasuryoneachsharesold:or,ifpaidinproperty,thekind,quantityand
valueofthesamepershare.
10.Ofthestocksold,howmuchremainsunpaidandsubjecttoassessment?
4
P.O.Box470881LittleDeeDrivePawnee,OK74058Phone:918‐762‐3621Fax:918‐762‐6446

DocumentationRequirements
II.Ownership
1. ProvideforeachOwner:
 A.Name
 B.Address
 C.TribalAffiliation
 D.EnrollmentNumber
 E.PercentofOwnership
 F.AmountofInvestment
 G.MethodofInvestment
 •Cash
 •Equipment
2. Loaninformationorpromissorynoteindicatingwhotheloanisfrom.
3. Percentofvotingcontrolandpositioninthefirm.
4. Nameofallotherfirmsinwhichtheownerholdsorhaswithinthepastyearanownershipinterest
(other than publicly held corporations and similar ownerships solely for investment) or a
managementposition.
5. Listanymanagementfee,equipment rental,bonuses or otherarrangementsthatwill provide
paymenttonon‐Indianownersbeyondtheirshareofprofitsandsalaries,asindicatedabove.
6. Identifyanyownerormanagementofficialofthenamedcompany who is or has been an
employeeofanothercompanythathasanownershipinterestinorapresentbusinessrelationship
withsaidcompany;presentbusinessrelationshipsincludesharedspace,equipment,financing,or
employeesaswellasbothcompanieshavingsomeofthesameowners.
7. Indicate if this company or other companies with any of the same officers have previously
receivedorbeendeniedcertificationorparticipationasanIndianpreferencefirmanddescribe
thecircumstances.Indicatethenameofthecertifyingauthorityandthedateofsuchcertification
ordenial.
5
P.O.Box470881LittleDeeDrivePawnee,OK74058Phone:918‐762‐3621Fax:918‐762‐6446

Certification
Idosolemnlydeclareandaffirmthatthecontentsoftheforegoingdocumentsaretrueandcorrectand
include all information necessary to identify and explain the operation of
__________________________________ (Name of Business), as well astheownershipthereof.The
undersignedinadditionswearsthatthisbusinessisatleast51%ownedbyoneormoremembersofa
federallyrecognizedTribewhosemanagementanddailybusinessoperationarecontrolledbyoneormore
suchindividuals.
Anymaterialmisrepresentationwillbegroundsfordenialorrevocationorcertificationbymembersof
thePawneeNationTERO.ByexecutingthiscertificationIherebysubmittothejurisdictionofthePawnee
NationTribalCourt.
____________________________________________ ________________________________
SignatureofAuthorizedOfficialDate
____________________________________________
PrintorTypeName
____________________________________________
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Incompleteapplicationscannotbesubmitted.Allapplicationsmaybesubjecttoasitevisit.AsofSeptember1,2019, allapplicationswillberequiredtopaya$100nonrefundableapplicationprocessingfee.Ifthebusinessiscertified, theyearonecertificationfeewillbewaived. PerPawneeNa

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Completed 31 January 2021

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