Fort Peck Community College Phone: (406) 768 6300
605 Indian Avenue Fax: (406) 768 6301
Po Box 398 www.fpcc.edu
Poplar MT 59255
TRIBAL VERIFICATION FORM
Please return to | Fort Peck Community College, Po Box 398, Poplar MT 59255
Release of Information
Students who are Enrolled or Descendants of a Federally Recognized Tribe must complete this form.
Student Name _____________________________
Place of Birth ______________________________
City State
Name of Tribe _____________________________
Location of Tribe ___________________________
City State
Date of Birth ______________________________
Social Security # ____________________________
Enrolled ________ Descendant* ________
Tribe _____________________________________
(ie: Sioux, Assiniboine)
*IF YOU ARE NOT ENROLLED, BUT YOUR PARENT/GRANDPARENT IS, COMPLETE THIS SECTION*
Mother’s Name ____________________________
Maiden Name _____________________________
Enrolled ____ 1
st
Descendant ____Tribal Affiliation ____________________ Enrollment # ____________
Father’s Name _________________________________________________________________________
Enrolled ____ 1
st
Descendant ____Tribal Affiliation ____________________ Enrollment # ____________
Grandmother’s Name _______________________
Maiden Name _____________________________
Enrolled ____ 1
st
Descendant ____Tribal Affiliation ____________________ Enrollment # ____________
Grandfather’s Name ____________________________________________________________________
Enrolled ____ 1
st
Descendant ____Tribal Affiliation ____________________ Enrollment # ____________
I hereby authorize the Tribal Enrollment Office to release my tribal blood certification to the Fort Peck
Community College, for the purpose of college enrollment only. I understand the information is
confidential and the above organization will use it only for the stated purpose.
___________________________________________ ________________________________
Student Signature Date
=====================================================================================
TO BE COMPLETED BY ENROLLMENT OFFICE (or attach CIB)
I certify that the above named person is a member/descendent of this tribe as:
Full Enrolled
1
st
Descendant
2
nd
Descendant
Enrollment Number _________________________
Blood Degree ______________________________
_________________________________________
_________________________________________
Official Signature
Agency Name
_________________________________________
_________________________________________
Date
Address
_________________________________________
City/State/Zip
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome