RedNation, Inc. 
Enrollment Application
Send to: Giti Equa Yonv Smith, CEO
357 Cleveland Street, Blairsville, Georgia 30512
Phone: 1-706-781-6763
Office Hours: 9am – 5pm EST Tues. – Sat.
E-mail: moreinfo@rednation.net
(Please PRINT LEGIBLE and fill in ALL blank spaces)
(Birth Date MUST be included)
Name_____________________________________________________________________________Date______________________
Address & Zip Code___________________________________________________________________________________________
_____________________________________________________________ E-mail:________________________________________
Phone (Area Code)_____________________________ Date of Birth_________________________ Age______ M/F______
Tribe/Nation__________________________________ Amount of Enrollment Fee Included $_________________
Please check one: New Membership ______ Annual Renewal_____ Membership Card # __________________
X__________________________________
(Signature)
Please include Names & Addresses (with zip codes) of ALL other members of your family that are applying below:
(Please PRINT LEGIBLE and include ALL dates of birth)
1. Name__________________________________________ Date of Birth_____________________ Age________ M/F_______
Address_______________________________________________________________________________________________
Membership Status: New_______ (or) Membership Card # ________________
2. Name__________________________________________ Date of Birth_____________________ Age________ M/F_______
Address_______________________________________________________________________________________________
Membership Status: New________ (or) Membership Card # ________________
3. Name__________________________________________ Date of Birth_____________________ Age________ M/F________
Address________________________________________________________________________________________________
Membership Status: New_____ (or) Membership Card # _________
(If any more space is needed, attach separate form)
The required annual enrollment is $10.00 per person per card. Enrollment fees cover costs of processing, printing materials,
and mailing. Ages 1-12 are free and ages 65 or older are also free. Birth Dates determine time of renewal. Enrollment Cards are for enrollment privileges ONLY !!!
NOT for any medical, federal privileges or benefits thereof.
Any donation is welcome.
X____________________________
(Signature)