Ka Wai Ola - Office of Hawaiian Affairs, Volume 30, Number 1, 1 January 2013 — Page 11 Advertisements Column 1 [ADVERTISEMENT]

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DECLARATIOH *► I affirm the unrelinquished sovereignty of the Native Hawaiian people, and my intent to participate in the process of self-governance. *► I have a significant cultural, social or civic connection to the Native Hawaiian community. *► I am a Native Hawaiian: a lineal descendant of the people who lived and exercised sovereignty in the Hawaiian islands prior to 1 778, or a person who is eligible for the programs of the Hawaiian Homes Commission Act, 1 920, or a direct lineal descendant of that person. GENERAL INF0RMATI0N (please print) This section is information about the person who is registering to be a part ofthe Kana'iolowalu Registry. I through 7 must be completed. 1. FIRST NAME MIDDLE NAME LAST NAME NAME ON BIRTH CERTIFICATE 2. FIRST NAME MIDDLE NAME LAST NAME 3. MAILING ADDRESS CITY STATE ZIP 4. 5. EMAIL ADDRESS DAYTIME ĪELEPHONE NUMBER 6. 7. DATE OF BIRTH ( MM/DD/YYYY ) PLACE OF BIRTH (CITY, STATE ) 8. □ MALE □ FEMALE (eheek box) ANCESTRAL HOME(S) (PLACE, ISLAND ) This is the area(s) your Hawaiian ancestors are from. SIGNATURE *► I affirm the Kana'iolowalu Declaration. *► I authorize the organization named or government agency such as the Department of Health to release my information for the purposes of confirming my ancestry for this registry. I hereby declare that the information provided is true and accurate to the best of my knowledge. If any of the statements are proven to be misleading or false my name may be removed from the official list and other penalties may be imposed under law. REGISTRANT /PERSON COMPLETING FORM (PRINT) SIGNATURE DATE (MM/DD/YYYY) RELATIONSHIP OF PERSON TO REGISTRANT CONTACT # OR EMAIL (IF NOT REGISTRANT)

VERIFICATION 0F NATIVE HAWAIIAN ANCESTRY lf you have already verified your ancestry through another program, please indicate this here. You do not need to provide the records again. Or, please attach a copy of your birth certificate, or documentation of any kind that says Hawaiian or part-Hawaiian. Please do not submit original copies. I verify my ancestry through the following: (CHECK ALL THAT APPLY) Birth certificate Other certificate listing Hawaiian or Part-Hawaiian (death, marriage, baptismal, etc) Attended The Kamehameha Schools, Class of , and attest to being Native Hawaiian Dept of Hawaiian Home Lands Lessee Kamehameha Schools Ho'oulu Hawaiian Data Center Operation 'Ohana # Hawaiian Registry at OHA # Kau Inoa (ancestry confirmed) Other: lf "Hawaiian" or "part Hawaiian" is not on the birth certificate, or if no certificate is produced: Full name of the parent(s) who is/are Native Hawaiian as it appears on her/his birth certificate. FIRST NAME (please print) MIDDLE NAME LAST NAME BIRTH DATE (MM/DD/YYYY) BIRTH PLAOE FIRST NAME (please print) MIDDLE NAME LAST NAME BIRTH DATE (MM/DD/YYYY) BIRTH PLAOE Please sign, date and mail completed form to: Native Hawaiian Roll Commission 71 1 Kapi'olani Blvd., Suite 1 150 Honolulu, Hawai'i 96813 lf you have any questions eall (808) 594-0088. The form ean also be filled in and submitted on-line at www.kanaiolowalu.org/registernow. (OFFICE USE) NUMBER DATE RECD DATA ENTRY I