Native American Verification Form
Release of Information
Students who are Enrolled or Descendants of a Federally Recognized Tribe must complete this form.
I, ___________________________, hereby authorize the Tribal Enrollment Office to release a tribal blood certification to the Institute of
American Indian Arts, for the purposes of college enrollment only. I understand the information is confidential and the above organization will use it
only for the stated purpose.
Student Name:______________________________ Descendant of:_________________________________
Applicant’s Name
Applicant’s Name _____________________________________________________ _______________________
First
Middle
Last
Date of Birth___________________________________
Former Name
Signature
Social Security _______________________________
Enrolled:_____1st Descendant _____Tribal Affiliation: ________________________________________________
Mother’s Name:______________________________________________________________________________
First
Middle
Last
Former Name
Enrolled:_____1st Descendant _____Tribal Affiliation: ____________________________Enrollment #:_________
Father’s Name:______________________________________________________________________________
First
Middle
Last
Enrolled:_____1st Descendant _____Tribal Affiliation: ____________________________Enrollment #:_________
Please provide your current address to update your records and please forward form to your Tribal Enrollment
Department for enrollment verification.
Address:______________________________________City/State/Zip___________________________________
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THIS SECTION IS TO BE COMPLETED BY A TRIBAL CERTIFYING OFFICIAL:
I hereby certify that the above named applicant is _____________________degree________________________
Indian blood according to available records.
Name of Tribe
Enrollment #_________________________________1st Descendant #:__________________________________
________________________________________________
Signature of Certifying Official
_______________________________________
Date
Return To:
Institute of American Indian Arts
Office of Admissions
83 Avan Nu Po Road
Santa Fe, NM 87508
800.604.8622 FAX 505.424.4500