Educational Incentives Program Application

Student Information

Last Name:*

First Name:*

Middle Initial:

Tribal Enrollment Number:*

Date of Birth*

Age:*

Parent/Guardian Name:

I am the legal parent/guardian of the above child and am the permanent custodial parent.

I certify.

Mailing Address:*

Apt./Box/Space:

City:*

State:*

Zip Code:*

Phone Number:*

Email Address:*

Please select the service you are applying for:*

Select or enter value

Upload appropriate files here

Please note, we are limited to accepting 10 documents with this drop box.

Drag and drop files here or

(Not required for Grades and Attendance Incentive, Pre-Graduation Assistance or Post Graduation Recognition)

Company/Location Name:*

Contact Person:*

Phone:*

Email Address:*

Under penalty of perjury, I hereby certify that all information provided above is true and accurate.

I certify*

Date:*

Send me a copy of my responses