| Kansas Delaware Membership Application |
| (PLEASE PRINT IN INK) |
| A copy of the applicant's birth certificate is required ALL INFORMATION WILL REMAIN CONFIDENTIAL |
DATE OF APPLICATION _________________________________ ________________________________________________________________________________________________________ LAST NAME FIRST MIDDLE MAIDEN DATE OF BIRTH ______________________ ____ MALE ____ FEMALE ________________________________________________________________________________________________________ MAILING ADDRESS (NUMBER, STREET, ROUTE, BOX) CITY STATE ZIP PHONE NUMBER ( ______ ) _____________________ E-MAIL ____________________________________________ MILITARY SERVICE _____________________________________________________________ Is applicant a member of any other tribe? _____ Yes ____ No If yes, enter name of tribe____________________ Is applicant adopted? _____ Yes _____ No Ancestor on 1866 Roll ___________________________________________________________ (List your ancestors below beginning with Delaware great–great–grandparent, great–grandparent, etc.)  . |