N UNKUWARRIN YUNTI OF SOUTH AUSTRALIA INC CONFIRMATION OF

N UNKUWARRIN YUNTI OF SOUTH AUSTRALIA INC CONFIRMATION OF






ABORIGINAL AND TORRES STRAIT ISLANDER COMMISSION

NN UNKUWARRIN YUNTI OF SOUTH AUSTRALIA INC CONFIRMATION OF UNKUWARRIN YUNTI OF SOUTH AUSTRALIA INC


Confirmation of

Aboriginality or Torres Strait Islander Descent


Applicant Declaration


I _________________________________________________Date of Birth _____________

(Print name in BLOCK letters)


of ________________________________________________________Postcode________

(Print address in BLOCK letters)

______________________________________________Tel: ________________________

Do solemnly and sincerely declare that I am of Aboriginal/Torres Strait Islander* descent.

I identify as an Aboriginal/Torres Strait Islander* and am accepted as such by:


_________________________________________________________________________

(Name of Community to whom I am known and accepted)


_______________________________________ ______________________________

(Name of Community Member or Nunkuwarrin Yunti Signature of person confirming

staff member to whom I am known and accepted) Contact number:


Mother’s Details

Date of Birth

Aboriginal TSI

Father’s Details

Date of Birth

Aboriginal

TSI



Mother’s name



Yes/No*



Father’s name



Yes/No*



Grandmother’s name



Yes/No*



Grandmother’s name



Yes/No*



Grandfather’s name



Yes/No*



Grandfather’s name



Yes/No*

* Delete whichever is not applicable


Birth certificate attached? □ Yes No □


I make this solemn declaration conscientiously believing the statements contained in this declaration to be true and correct.


______________________________

Signature of Applicant

It is hereby confirmed that the above-named applicant has provided sufficient evidence to indicate that he/she* is of Aboriginal/Torres Strait Islander* descent and is accepted as such by the Community in which she/he* lives.

*Delete whichever is not applicable

(Office use only)


Date of Meeting: ____________________ Signature: _____________________________

Authorised Signatory


(Common Seal Name: ________________________________

to be affixed)

Signature: _____________________________

Authorised Signatory


Name: ________________________________

182-190 Wakefield Street, Adelaide SA 5000 (PO Box 7202 Hutt Street, Adelaide 5000)

Tel: (08) 8406 1600 Fax: (08) 8232 0949 Email: [email protected]





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