Hosted By:

Native American Church of AShii Be To

66th Annual
Native American Church
of North America Conference
Registration Packet
for the
2012-2015 Executive Officers
President Sandor Iron Rope (Lakota)
Vice-President Leo Dayish (Din)
Secretary Sheila White Eagle (Din)
Treasurer James Tso (Din)
Editor-in-Chief Sarah Fanman (Cheyenne/Din)

May 7, 2014

The Native American Church of North America invites all NACNA affiliated chapters,
Delegate (s) at large, the National Council of Native American Churches and their
families to the 66th Annual NACNA Conference at Red Lion Hotel, Salt Lake City, UT
June 18-21, 2015 . The conference is hosted by the Native American Church of
AShii Be To.
To affiliate with the NACNA complete the application and attach required
documents with fee. The documentation of your chapter will allow the NACNA to
better serve our Church and document affiliated chapters and members. Preregistration is encouraged to facilitate a smooth registration process. Please mail
forms prior to the annual conference.
Complete and return the enclosed application Chapter and membership card
application (pages 8-11) , state charter, by-laws , $250.00 affiliation fee (money
order, all documents may be submitted at annual conference) the by June 5,
2014. The documents and fee are required to recognize your local NAC Chapter
as an affiliate of NACNA for and as a registered participant in the 65th Annual
NACNA Conference (affiliation good through June 2015).
Make cashiers check or money order payable to Native American Church of North
America, Inc. and return with the application to:
James Tso, NACNA Treasurer
P.O. Box 976
Fruitland, NM 87416
MEMBERSHIP CARD APPLICATION: Complete the enclosed membership card

application by June 5, 2014 and return to James Tso, NACNA Treasurer. This
application should be completed when purchasing membership card(s) for yourself
or other individuals (i.e. family members or others who cannot attend the
convention). You may make copies of this application form to keep on file at your
local chapter for other individuals who may want to apply at a later time. Keep in
mind that membership cards cost $3.00 and are valid through June 30,
2015.Completed applications may also be submitted at the annual conference .
Thank you for your time and cooperation. For further information regarding the
membership cards or the pre-registration process, please contact James Tso at
jmsrt51@yahoo.com or (505) 686-0333.
Date: _________________

Chapter: ________________________________________
______________________

Affiliation Number:

DELEGATES:
Name:____________________________
Address:________________________________________
Telephone:__________________________
_________________________________________
E-mail (optional):____________________ Tribal
Affiliation:_________________________________
Name:_____________________________
Address:________________________________________
Telephone:__________________________
_________________________________________
E-mail (optional):____________________ Tribal
Affiliation:_________________________________
ALTERNATE DELEGATE(S):
Name:____________________________
Address:________________________________________
Telephone:__________________________
_________________________________________

E-mail (optional):____________________ Tribal

Affiliation:_________________________________
Name:_____________________________
Address:________________________________________
Telephone:__________________________
_________________________________________
E-mail (optional):____________________ Tribal
Affiliation:_________________________________

CHECKLIST FOR REGISTRATION:

All items on the checklist must be completed for NACNA affiliation.

State Charter submitted

Yes

No

Organization By-Laws submitted

Yes

No

150 Dry Peyote Buttons Received

Yes

No

Registration Application submitted

Yes

No

Convention Registration Fee Paid

Yes
$250 payable to NACNA (money order or cashiers check only)

No

Date:
____________________________
Chapter: ________________________________________________Affiliation Number:
_____________________________
(print or type)
When is your next local election of officers? ______________________________
(month/year)

Name/Address of Current Officers: (print or type)

Term Ending:
___________________
PRESIDENT

Name:____________________________
Address:________________________________________

Telephone:__________________________
_________________________________________
E-mail (optional):____________________ Tribal
Affiliation:_________________________________
VICE-PRESIDENT

Name:____________________________
Address:________________________________________
Telephone:__________________________
_________________________________________
E-mail (optional):____________________ Tribal
Affiliation:_________________________________
SECRETARY

Name:_____________________________
Address:________________________________________
Telephone:__________________________
_________________________________________
E-mail (optional):____________________ Tribal
Affiliation:_________________________________
TREASURER

Name:____________________________
Address:________________________________________
Telephone:__________________________
_________________________________________
E-mail (optional):____________________ Tribal
Affiliation:_________________________________
CUSTODIAN

Name:____________________________
Address:________________________________________
Telephone:__________________________
_________________________________________
E-mail (optional):____________________ Tribal
Affiliation:_________________________________

Local N.A.C Chapter:

(print or type)

Address:
(print or type)

Local N.A.C Chapter President

(print or type)

Has Your Chapter Paid Their Annual Affiliation Fee for the current year? YES _______
First Name:__________________________________
Name:__________________________________

NO _______

Last

(print or type)

(print or type)

Address:
(print or type)

Tribe:

Tribal Enrollment Number:

(print or type)

First Name:__________________________________
Name:__________________________________

Last

(print or type)

(print or type)

Address:
(print or type)

Tribe:

Tribal Enrollment Number:

(print or type)

Office Use Only: Affiliation Number:

Expires: 6/30/2015
Office Use Only: Affiliation Number:
Expires: 6/30/2015

Card Number:
Card Number:

First Name:__________________________________
Name:__________________________________

Last

(print or type)

(print or type)

Address:
(print or type)

Tribe:

Tribal Enrollment Number:

(print or type)

Office Use Only: Affiliation Number:

Expires: 6/30/2015

Card Number:

First Name:__________________________________
Name:__________________________________

Last

(print or type)

(print or type)

Address:
(print or type)

Tribe:

Tribal Enrollment Number:

(print or type)

First Name:__________________________________

Last

Name:__________________________________
(print or type)

(print or type)

Address:
(print or type)

Tribe:

Tribal Enrollment Number:

(print or type)

Office Use Only: Affiliation Number:

Expires: 6/30/2015
Office Use Only: Affiliation Number:
Expires: 6/30/2015
Office Use Only: Affiliation Number:
Expires: 6/30/2015

Card Number:
Card Number:
Card Number:
Please Complete All Blanks
Please Complete All Blanks

First Name:__________________________________
Name:__________________________________

Last

(print or type)

(print or type)

Address:
(print or type)

Tribe:

Tribal Enrollment Number:

(print or type)

Office Use Only: Affiliation Number:

Expires: 6/30/2015

Card Number:

First Name:__________________________________
Name:__________________________________

Last

(print or type)

(print or type)

Address:
(print or type)

Tribe:

Tribal Enrollment Number:

(print or type)

Office Use Only: Affiliation Number:

Expires: 6/30/2015

Card Number:
Please Complete All Blanks

First Name:__________________________________
Name:__________________________________

Last

(print or type)

(print or type)

Address:
(print or type)

Tribe:

Tribal Enrollment Number:

(print or type)

Please return Membership Card Application by June 5, 2013 to

James Tso, NACNA Treasurer.
P.O. Box 976
Fruitland, NM 87416
Make check/money order payable to Native American Church of North America, INC
Please return Membership Card Application by June 5, 2014 to

James Tso, NACNA Treasurer.

P.O. Box 976
Fruitland, NM 87416
Make check/money order payable to Native American Church of North America, INC

NATIVE AMERICAN CHURCH of NORTH AMERICA, INC.

United States, Canada and Mexico

The
65th Annual Conference
June 12-15, 2014
Wind River Hotel & Casino
Riverton, WY

NATIVE AMERICAN CHURCH of NORTH AMERICA, INC.

United States, Canada and Mexico

The
65th Annual Conference
June 12-15, 2014
Wind River Hotel & Casino
Riverton, WY

NATIVE AMERICAN CHURCH of NORTH AMERICA, INC.

United States, Canada and Mexico

The
65th Annual Conference
June 12-15, 2014
Wind River Hotel & Casino
Riverton, WY

NATIVE AMERICAN CHURCH of NORTH AMERICA, INC.

United States, Canada and Mexico

The
65th Annual Conference
June 12-15, 2014
Wind River Hotel & Casino
Riverton, WY

NATIVE AMERICAN CHURCH of NORTH AMERICA, INC.

United States, Canada and Mexico

The
65th Annual Conference

June 12-15, 2014

Wind River Hotel & Casino
Riverton, WY

NATIVE AMERICAN CHURCH of NORTH AMERICA, INC.

United States, Canada and Mexico

The
65th Annual Conference
June 12-15, 2014
Wind River Hotel & Casino
Riverton, WY