Application to become an IBN Community Member IBN Charitable Foundation 1. Background Step 1 of 7 – Personal Information: 14% First Name(Required) Last Name(Required) Date of Birth(Required) DD slash MM slash YYYY Postal Address(Required) Residential Address (If the same Postal Address – leave blank)Phone(Required)Email address(Required) How do you prefer to be contacted?(Required) Phone Email Post Mother Mother What is your mother’s name?(Required) Please tell us about your grandparents on your mother’s sideWhat is your grandmother’s name?(Required) What is your grandfather’s name?(Required) Father Father What is your father’s name?(Required) Please tell us about your grandparents on your father’s sideWhat is your grandmother’s name? What is your grandfather’s name? I declare that I am a: (tick one box only)(Required) Yinhawangka person Banyjima person Nyiyaparli person I am applying to the following Representative Corporation (please tick one box) for its endorsement as a member of that language group, and if eligible for membership of that Corporation:(Required) Minadhu Aboriginal Corporation Banyjima Aboriginal Corporation Milyuranpa Banyjima Aboriginal Corporation Nyiyaparli Aboriginal Corporation I endorse the person named on this application as being eligible to be a member of the IBN Community.Signature of Elder or Director Name of Elder or Director Date DD slash MM slash YYYY I declare that the above information in my application is true and accurate and authorise IBN to verify as necessary.(Required) I declare that the above information in my application is true and accurate and authorise IBN to verify as necessary. I consent to my name being entered as an IBN Community Member under the IBN Charitable Foundation and agree to be bound by the terms and conditions of the IBN Charitable Foundation Trust Deed.(Required) I consent to my name being entered as an IBN Community Member under the IBN Charitable Foundation and agree to be bound by the terms and conditions of the IBN Charitable Foundation Trust Deed. I agree to tell IBN if I receive any benefits (financial or other) from a Native Title Agreement or another foundation related to another Native Title Claim or Language Group, when making an application for assistance from the IBN Charitable Foundation.(Required) I agree to tell IBN if I receive any benefits (financial or other) from a Native Title Agreement or another foundation related to another Native Title Claim or Language Group, when making an application for assistance from the IBN Charitable Foundation. Signature Date DD slash MM slash YYYY Attachment checklist(Required) Please attach a copy of your birth certificate to this application. Please attach your completed Deed of Undertaking by an IBN Community Member. Remember you must also attach your completed application form for the Representative Corporation you ticked above (Question 4). FileMax. file size: 128 MB. Date DD slash MM slash YYYY Received by
