Native Hawaiian Roll Commission
DECLARATION ³ ³
@ X]Å id k_\ lei\c`ehl`j_\[ jfm\i\`^ekp f] k_\ EXk`m\ ?XnX``Xe g\fgc\# Xe[ dp `ek\ek kf gXik`Z`gXk\ `e k_\ gifZ\jj f] j\c]$^fm\ieXeZ\%
³ ³
@ _Xm\ X j`^e`Å ZXek ZlckliXc# jfZ`Xc fi Z`m`Z Zfee\Zk`fe kf k_\ EXk`m\ ?XnX``Xe Zfddle`kp%
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@ Xd X EXk`m\ ?XnX``Xe1 X c`e\Xc [\jZ\e[Xek f] k_\ g\fgc\ n_f c`m\[ Xe[ \o\iZ`j\[ jfm\i\`^ekp `e k_\ ?XnX``Xe `jcXe[j gi`fi kf (../# fi X g\ijfe n_f `j \c`^`Yc\ ]fi k_\ gif^iXdj f] k_\ ?XnX``Xe ?fd\j :fdd`jj`fe 8Zk# (0)'# fi X [`i\Zk c`e\Xc [\jZ\e[Xek f] k_Xk g\ijfe%
GENERAL INFORMATION
( PLEASE PRINT ) K_`j j\Zk`fe `j `e]fidXk`fe XYflk k_\ g\ijfe n_f `j i\^`jk\i`e^ kf Y\ X gXik f] k_\ BXeX¼`fcfnXcl I\^`jkip% ( k_ifl^_ . dljk Y\ Zfdgc\k\[%
VERIFICATION OF NATIVE HAWAIIAN ANCESTRY @] pfl _Xm\ Xci\X[p m\i`Å \[ pfli XeZ\jkip k_ifl^_ Xefk_\i gif^iXd# gc\Xj\ `e[`ZXk\ k_`j _\i\% Pfl [f efk e\\[ kf gifm`[\ k_\ i\Zfi[j X^X`e% Fi# gc\Xj\ XkkXZ_ X Zfgp f] pfli Y`ik_ Z\ik`Å ZXk\# fi [fZld\ekXk`fe f] Xep b`e[ k_Xk jXpj ?XnX``Xe fi gXik$?XnX``Xe% Please do not submit original copies. @ m\i`]p dp XeZ\jkip k_ifl^_ k_\ ]fccfn`e^1 ( CHECK ALL THAT APPLY ) 9`ik_ Z\ik`Å ZXk\ Fk_\i Z\ik`Å ZXk\ c`jk`e^ ?XnX``Xe fi GXik$?XnX``Xe [\Xk_# dXii`X^\# YXgk`jdXc# \kZ 8kk\e[\[ K_\ BXd\_Xd\_X JZ_ffcj# :cXjj f] VVVVVV# Xe[ Xkk\jk kf Y\`e^ EXk`m\ ?XnX``Xe ;\gk f] ?XnX``Xe ?fd\ CXe[j C\jj\\
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NAME ON BIRTH CERTIFICATE
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DAYTIME TELEPHONE NUMBER
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DATE OF BIRTH D D &; ;& P P P P
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BIRTH DATE D D &; ;& P P P P 9@IK? GC 8:<
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BIRTH DATE D D &; ;& P P P P 9@IK? GC 8:<
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SIGNATURE ³ ³ ³ ³ ³ ³
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Native Hawaiian Roll Commission .(( BXg`¼fcXe` 9cm[%# Jl`k\ ((,' ?fefclcl# ?XnX`¼` 0-/(* @] pfl _Xm\ Xep hl\jk`fej ZXcc /'/ ,0+$''//% K_\ ]fid ZXe Xcjf Y\ Å cc\[ `e Xe[ jlYd`kk\[ fe$c`e\ Xk nnn%bXeX`fcfnXcl%fi^&i\^`jk\iefn% F==@:< LJ< ELD9<I VVVVVVVVVV
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