Chugach Regional Portal Chugach Regional Portal For Shareholders of Chugach Alaska Corporation For Shareholders of Chugach Alaska Corporation

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Descendant Registration Form 2017

Chugach Alaska Corporation and the Chugach Heritage Foundation are collecting this information to improve communications with descendants who may become CAC Shareholders and/or be eligible for scholarships and other important benefits.

Descendant Information - PART 1

First Name:(*)
Please let us know your name.

Middle Name:(*)
Please give us your middle name.

Last Name:(*)
Please give us your last name.

Date of Birth:(*)
/ / Please give us your date of birth.

Enrollment #:(*)
Please give us your enrollment number.

If born after Dec. 17, 1971 - please use descendant's Birth Date, i.e. 12-18-1971.

Address:(*)
Please give us your address.

City:(*)
Please give us the city you live in.

State:(*)
Please give us the state.

Postal Code:(*)
Invalid Input

Primary Phone:(*)
Please give us your phone number.

Secondary Phone:
Invalid Input

Email Address:
Invalid Input

Custodian Name & Address (if younger than 18 years old):
Invalid Input

 

Original Shareholder Information - PART 2

Instructions: Please identify one original shareholder from whom the applicant is descended.

First Name:(*)
Please enter the first name of the shareholder.

Middle Name:
Invalid Input

Last Name:(*)
Please enter the last name of the shareholder.

Date of Birth:(*)
/ / Please enter the Date of Birth of the shareholder.

Your Email:(*)
Please let us know your email address.

(Registration Receipt is sent here)

Enrollment # of Shareholder:(*)
Please enter enrollment number of the shareholder.

Relationship to Applicant:(*)
Please enter the relationship to the applicant.

PRIVACY PROMISE: This information is confidential and will only be used for CAC & CHF purposes. It will not be sold, distributed or used for any other purpose. Descendants may review, update or remove their personal information from this descendant database by contacting CAC Shareholder Services at: (907) 563-8866.

 

CIB & Birth Certificate Notice - PART 3

You must mail or fax your Certificate of Indian Blood (CIB) and Birth Certificate to complete this Descendant Registration process. All originals will be sent back.

Mail or Fax to: Chugach Alaska Corporation, Shareholder Services, 3800 Centerpoint Drive, Ste. 1200, Anchorage, Alaska 99503 or Fax: (907) 261-8878.

Please tell us the status of these documents:(*)
Please enter the status of these documents to continue.

 

Certification Agreement & Signature - PART 4

1. The company and other persons or employers are released from all liability brought forth by any investigation resulting from my submission of this electronic application and the data contained here in.

2. The information in this application is true and complete to the best of my knowledge. Any falsification, misrepresentation, or omission on this application can be cause for denial or termination of being registered as a shareholder descendant.

3. In order to complete this descendant registration, I will need to mail or fax in a Certificate of Indian Blood (CIB) and a Birth Certificate for each applicant.

4. I have read and reviewed the information provided in this application and the above statements. By signing this application for registration of a shareholder descendant I certify that I understand all parts of it and have answered all questions completely and fully.

5. I understand that my Social Security Number (SSN) and my descendants SSN number will not be submitted electronically through this application for safety and identity theft prevention measures. Please do not email this information to our office.

6. I understand that by typing my name in the signature box below and submitting this application electronically, this becomes a legal and binding contract of registration.

Shareholder or Descendant Signature(*)
Please enter your name.

Today's Date:(*)

Please enter today's date.

Please enter the code in the box below to submit the application.(*)
Please enter the code in the box below to submit the application.
Please enter the code to submit the application.

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