Verification Form Chairman’s Back-To-School $100 Gift Card
for
Off-Reservation Enrolled Students - Academic Year 2017-2018 All
information is required. REQUESTOR MUST BE THE LEGAL
PARENT/GUARDIAN IN REGARDS TO CUSTODIAL ISSUES. Information will be
verified when received. Gift card will be sent to requestor address
listed below. Incomplete forms will
not be processed. ABSOLUTE DEADLINE: POSTMARKED BY OCTOBER 27,
2017 – School Enrollment is REQUIRED (These can be obtained from
current school)
PARENT/LEGAL GUARDIAN – Requestor PLEASE PRINT. ALL INFORMATION
IS REQUIRED.
Last Name First Name DOB
Email Enrollment # (MHA Members Only)
301U-
Address City State Zip
Contact Phone Are you a Veteran? Branch of Service What MHA
tribal segment do you vote?
ELIGIBLE CHILDREN – (K Through 12 - Enrolled MHA Nation
Member’s) PLEASE PRINT Last Name Child 1 First Name Child 1 Gender
DOB Grade Enrollment #
301U-
School Name Address of School City State Zip
Last Name Child 2 First Name Child 2 Gender DOB Grade Enrollment
#
301U-
School Name Address of School City State Zip
Last Name Child 3 First Name Child 3 Gender DOB Grade Enrollment
#
301U-
School Name Address of School City State Zip
Last Name Child 4 First Name Child 4 Gender DOB Grade Enrollment
#
301U-
School Name Address of School City State Zip
* For additional Children use another form. Form can be
downloaded at www.mhasatelliteoffice.com
☐ By checking this box, I understand that all information is
true to my knowledge. I understand this document is legally binding
for the purposes of validity, enforceability, and admissibility. I
understand any fraudulent information can affect any future MHA
benefits. _______________________________________________
_____________________ Parent/Legal Guardian Date
MANDAN, HIDATSA, & ARIKARA NATION THREE AFFILIATED TRIBES *
FORT BERTHOLD RESERVATION Chairman, Mark N. Fox * Bismarck
Satellite Office
107 WEST MAIN AVENUE, SUITE #200, BISMARCK, ND 58501
9.22.17 Revised Scan Letter Gift
CardFlyerOffRez2017GiftCardDISTRIBNationwideForm_GiftcardBk2SchoolReturn
Address (7)
