St. Mary's Native Corporation

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SMNC Shareholder Personal Data Form

First Name

Middle Name

Last Name

Suffix

Previous Name (Attach copy of marriage certificate or copy of court document.)

Upload File

Upload supported file (Max 15MB)

Address

Date of Birth

Email

Phone

SSN

Would you like SMNC to send you a Will Form?

Yes

No

Comments, if any

Shareholder Signature

Your Signature

If a shareholder signs with an “X”, two (2) witnesses must sign below:

Witness 1 Name

Witness 2 Name

Witness 1 Signature

Witness 2 Signature

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