Tribal history
book available
by mail
Siletz Tribal History Book Request Form
(One per enrolled Tribal member)
First Name ________________________ Last Name ________________________
The news Siletz Tribal history book,
The People Are Dancing Again, can be
mailed to those Tribal members who did
n6t receive a book at one of the November
book distributions. To receive a book,
complete and submit a book request
form to:
ATT: Tribal History Book
Confederated Tribes of Siletz Indians
P.O. Box 549
Siletz, OR 97380-0549
Book request forms (right) are avail
able online on the Tribe’s website -
w^vw.csti.nsn.us - and in this month’s area
office newsletters.
The form states that you must submit
a photocopy of your picture identifica
tion or a Certification of Indian Blood
Degree (CIB). To obtain a CIB, contact
Enrollment Department staff toll-free
at 800-922-1399, ext. 1258, or direct at
541-444-8258.
Acceptable photo identification
includes Tribal photo enrollment identifi
cation, a driver’s license, a state identifica
tion card, a student body card, passport,
Armed Forces pass, firearms license or
other government-issued ID.
In the event a Tribal member (adult
or minor) has no photo identification,
another person who does have photo ID
can sign the form in front of the notary
attesting that the Tribal member is the
person named on the form based on the
fact that they personally know that Tribal
member.
If you have any questions about this
process, please contact Assistant Gen
eral Manager Bonnie Petersen toll-free
at 800-922-1399, ext. 1210, or direct at
541-444-8210; or via e-mail at bonniep@
ctsi.nsn.us.
8 . •
Siletz News
M.I. ________
Roll # __________
If you are applying on behalf of a Tribal member who is a minor, please list minor’s name here:
First Name ________________________ Last Name ________________________
M.I. ________
Roll # __________
Street Address ___________________________________________________________________________________________
Mailing Address _______________________________________________
City ___________________________________________
[ ] This is a new address
State
ZIP
Phone Number(s) ______________________________________ E-mail Address ___________________
I am requesting a copy of the Siletz Tribe’s history book, The People Are Dancing Again. I understand that each Tribal
member is entitled to one free book. I confirm by my signed and dated signature below that I am the person listed above and am
an enrolled Tribal member or that I am signing on behalf of a minor enrolled Tribal member who is my legal dependent.
Return form along with a photocopy of
picture identification or Tribal CIB or if you
do not have picture identification, sign and
date form in the presence of a Notary Public
(see below)
Signature: _____________________________________________
Date: __________________________________________________
INDIVIDUAL ACKNOWLEDGEMENT
STATE OF ________________________ )
COUNTY OF ______________________ )
On the_____ day of_______________ , 201__ ,____________________________________ , personally appeared before me:
____________ whom I know personally.
____________ whose identity I verified on the basis of______________________________________ a credible witness who
produced their photographic ID and who verified on oath or affirmation that the individual appearing before the notary
public as the signer of the document is the person named in the document.
____________ whose identity I verified on the basis of________________________________________ a credible witness who
produced their photographic ID and who verified on oath or affirmation that they are completing this form on behalf of
a Tribal member minor.
January ZOl.Ku
Notary Public
My Commission expires: