Banyjima Aboriginal Corporation Application Banjyma Aboriginal Corporation (ICN #3825): - Application for Membership Name:(Required) Residential Address:(Required) Mailing Address: Date of Birth:(Required) DD slash MM slash YYYY Phone: I am Banjyma through my:Mother Mother Father Father Grandfather(Required) Grandfather MotherGrandmother Grandmother Mother’s Name(Required) Father’s Name(Required) Grandfather’s Name(Required) Grandmother’s Name(Required) Are you a claimant of another Native Title Claim?(Required) Yes No If yes, please state with Native Title Claim:(Required) Other than benefits from Gumala, I have(Required) have not received benefits (financial or other) from another Language Group and/or Native Title Agreement relating to another Native Title Claim or from a Foundation elated to another Native Title Claim and hereby undertake to notify the Corporation immediately if Ido receive such benefits. Details of benefits received from other Claims if applicable):I consent to my name being entered onto the Register of Banjyma Aboriginal Corporation members & I agree to abide by the Banjyma Aboriginal Corporation rule book. I consent to my name being entered onto the Register of Banjyma Aboriginal Corporation members & I agree to abide by the Banjyma Aboriginal Corporation rule book. I consent to my name being provided to other registered native title bodies relating to other native title claims. I consent to my name being provided to other registered native title bodies relating to other native title claims. Signature Date DD slash MM slash YYYY
