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CERTIFICATION OF NATIVE AMERICAN HERITAGE

I__________________________________________HEREBY CERTIFY THAT I AM
OF NATIVE AMERICAN DESCENT. THIS ANCESTRY PERTAINS TO FULL OR MIXED
BLOOD OF THE INDIGENOUS PEOPLES OF NORTH AMERICA.

TO THE BEST OF MY KNOWLEDGE,MY HERITAGE DERIVES FROM THE
_________________________________PEOPLE.

I GIVE PERMISSION TO THE METIS NATION OF THE UNITED STATES TO USE 
THIS CERTIFICATION IN ANY  CAPACITY THEY DEEM NECESSARY FOR
VERIFICATION OF MY NATIVE AMERICAN HERITAGE AND/OR TO HELP IN THE
ACKNOWLEDGEMENT AND REPRESENTATION OF THE METIS IN NORTH AMERICA.

ALL INFORMATION I SUBMIT IN THIS CERTIFICATION IS TRUE AND ACCURATE
TO THE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ANY 
INTENTIONALLY MISLEADING OR FALSE INFORMATION WILL RESULT IN
IMMEDIATE DISMISSAL AND/OR PROSECUTION FROM THE METIS NATION OF
THE UNITED STATES.
 
SWORN BEFORE ME THIS_________DAY OF___________________19____
 

                                                                                                                       
_____________________________     __________________________
COUNTY                            CITY & STATE

_____________________________     __________________________
APPLICANTS SIGNATURE              NOTARY PUBLIC

this document is exclusively for use by the Metis Nation of the
United States



                                                           (form 100)