Ka Wai Ola - Office of Hawaiian Affairs, Volume 8, Number 9, 1 September 1991 — Page 21 Advertisements Column 1 [ADVERTISEMENT]

Ohana self enrollment form

OFFICE OF HAWAIIAN AFFAIRS HAWAIIAN ANCESTRY ENROLLMENT Phase I CONFIDENTIAUOFFICE USE ONLY ' INSTRUCTIONS: To be completed by adults 18 years and older of Hawaiian ancestry and those who are less than 18 years and have chitdren. Please | fill out this form to the best of your ability. Return to OHA Representative for final eheek. Mahalo for your kokua. ■ A.1. Inoa Piha (FULL LEGAL NAME) LĀST FiRST MIOOLE I A.2. Birth Name ! LAST (Maiden. FIRST MIOOLE [ A.3. Social Security No. — — J B.1. HeluWahi (Residence Address) I city state/country 2ip code I B,2. Helu Wahileka (Mailing Address) CĪTY STATE/COUNTRY ZlP CODE | C. Helu Kelepona (īelephone Number(s) Home: □ Unlisted Business: | D. □ Kane (Male) □ Wahine (Female) Marifal Status □ Single □ Married □ Divorced □ Widowed □ Separated □ Living with | E. La Hanau (Birthdate) / / | F.1. One Hanau (Birthplace) city / island state i country ■ F.2. Kula Iwi (Geographic Affinity) city/island state / country I G.1. Koko (Percentage of □ Less than 25% □ Q 25%-49% □ H 50%-74% □ T 75%-99% □ F 100% □ Hanai Hawaiian Blood) Check One I G.2. Other □ Am lndian, Alaskan □ Chinese □ Japanese □ Caucasian □ Filipino □ Portuguese □ Other I H. Rootname(s) of Hawaiian Lineage is/are: lsland/Place/Ahupua'a Mother's Side Grandmother Grandfather . Father's Side Grandmother Grandfather | I. Living 'Ohana Haku lf Known: (Person with Most Knowledge of 'Ohana) UST HRST MID°LE address phone: ■ J.1. Please list below your spouse (husband or wife), parent of children and children (including children over 18, deceased, married or not living in household). Please answer as mueh as possible. □ Husband ū Wife ū Mate Name: Birth date: / / % of Haw'n □ Kane □ Wahine ■

[ A B C D E F G H ' NAME Living in Percentage of Relationship I Please Write COMPLETE Name Birthdate Sex Marital Household Deceased Hawaiian" to Applicant LAST FIRST Ml MO DAY YR Status YES NO YES NO (Circle One) inA.1. I PARENT OF CHILD(REN) XXXXXX L Q H T F XXXXXXXXX - KEIKI (Ch,ldren) I LQHTF DSHd Hs [ LQHTF DSHdHs j L Q H T F D S Hd Hs I LQHTF DSHdHs [ LQHTF DSHdHs j LQHTF D S Hd Hs I L Q H T F D S Hd Hs j J.2. □ Check here if form for additional names is attached. No. of additional forms: j K. □ lf other Haw'n persons living in household, please list. | A B C D E I NAME Percentage of ! Please Write COMPLETE Name Birthdate Sex Hawaiian** Relationship to Applicant | LAST FIRST Ml MO DAY YR (Circle One) in A.1. I LQHTF Sb P Gp Gc I UA NN C N | L Q H T F Sb P Gp Gc I UA NN C N j L Q H T F Sb P Gp Gc I UA NN C N I L Q H T F Sb P Gp Gc I UA NN C N ■ L. □ For my Hawaiian ancestry, I have supporting/verifying documents. ■ M. □ We have a family genealogist LĀST FIRST MĪŌŌLĒ I ADDRESS PHONE | N. I hereby give permission for the use of the above information for genealogical purposes only. □ Yes □ No (lnitial) | I certify that the facts contained in this applieahon are true and correct to the best of my knowledge and understanding. I SIGNATURE DATE KA WAI OLA 0 OHA I REGISTRAR 0ATE | Fair lnformation Practice (Confidentiality of Personal Record) [ In accordancewith provisionsof Chapter92E of the Hawai'i Revised Statutes, no personal informationshall be disclosed except undercondition specified | by law and in the following manner: 1 ) personal records of individual applicants shall be accessible to the owner at any reasonable time at his/her request, ■ 2) such records shall be available to OHA staff who have direct custody of such records and who have demonstrated need to know 3) records will be I accessible to other individuals only at the expressed written permission of the owner. OHA shall establish appropriate administrative, leehnieal and physical | safeguards to ensure the security and confidentiality of records containing personal information relative to this enrollment procedure. oha.haelku »«9 | i>RLGLNAL_COPY I