LAST NAME: ________________________ FIRST NAME: ______________________

DATE OF BIRTH: ____________________ SSN: ______________________________

CURRENT HOME ADDRESS: __________________________________________________

_____________________________________________________________________________

CURRENT E-MAIL ADDRESS: _________________________________________________

TRIBAL AFFILIATION: _________________________ ENROLLED: _____ yes _____ no

Attachment A: If enrolled, attach verification of enrollment (e.g., enrollment card, certification, tribal letter, etc.) and tribal contact information.

If not enrolled, attach two (2) letters verifying that you are recognized as being Native American by your community of residence or origin (the letters must include the authors’ names, addresses and phone numbers, and at least one must identify your closest enrolled or recognized relative).

ADDITIONAL MATERIALS REQUIRED:

Attachment B: Provide a letter from the Minnesota law school you are attending indicating (1) whether you are currently in good academic standing, and (2) your class year.

Attachments C and D: Provide a copy of (C) your most recent Income Tax Return, and (D) a Financial Aid Statement from the Minnesota law school you are attending (showing scholarships, grants, loan eligibility, and unmet financial need).

Attachment E (optional): Provide a brief statement of circumstances further explaining your financial need (e.g., extenuating financial obligations, scholarships/grants not reflected on the Financial Aid Statement, or other pertinent financial information).

Attachment F: Provide a brief personal statement in support of your Application (suggested topics might include: (1) your vision of how you will use your law degree to benefit the Native American community, and (2) your personal experience(s) that demonstrate(s) your commitment to contributing to the Native American community).

Attachment G (optional): Provide a brief list of your community service and extra-curricular activities.

Attachment H: Provide at least one (1) Letter of Recommendation. (This letter may be submitted directly by the author so long as it is mailed/postmarked by November 1, 2011.)

I authorize the Minnesota American Indian Bar Association (MAIBA) to verify any of the information provided by me in my Application Cover Form or the attachments thereto with the law school that I attend and/or the Indian Tribe or band with which I am affiliated. I acknowledge and understand the requirements articulated for consideration as a possible scholarship recipient. I represent that all statements herein as well as in the documents attached hereto are true and correct to the best of my knowledge. I authorize MAIBA to release to the public my name, tribal affiliation and year in school.

Applicant’s Signature: ______________________________________

Date: ____________________________________________________