By signing this form below you acknowledge that you are a member of the Lost Cherokee of Arkansas and Missouri (aka Arkansas Cherokees, Cherokees on the Arkansas River, Lost Cherokee Group, Arkansas Cherokee Nation, Lost Cherokee Nation, Lost Cherokee Nation Economic Development Company, Lost Cherokee Tribe of Arkansas and Missouri), as represented by the Lost Cherokee of Arkansas and Missouri Inc., and tribal Headmen Cliff Bishop, Curtis Smith and Don Harness, as well as Tribal Councilmen Buddy Whiteley, John Brown, and Morris Chiles.  By signing this form below you also affirm that you are not a member of any other Native American entity, tribe or group-federally recognized or unrecognized. Signature:_____________________________________________ Printed Name:__________________________________________ Date:_________________________________________________ Lost Cherokee roll number:________________________________