I
OMB #: 1085-0001 Expires:
XX/XX/2018
Source Directory Business Listing Application
Please check the
appropriate box:
New Listing
Renewal/Changes
Individual
Group
Return To: U.S. Department of the Interior
I ndian Arts and Crafts Board
1849 C Street, NW, MS 2528-MIB
W ashington, DC 20240
Please print or type your
business information (see samples included):
Please print or type
Business name: ____________________________________________________________________________________________
Manager name: ____________________________________________ Tribe: ___________________________________
Owner name: ______________________________________________ Tribe: ___________________________________
CERTIFICATION: I certify that I am the owner of this enterprise and that I am an enrolled member of a federally recognized American Indian tribe or Alaska Native group. (A willfully false certification is a criminal offense [18 U.S.C. 1001] ):
Signature: ________________________________________________ Date: ____________________________________
Tribe or group: _____________________________________________________________________________________________
Notice: By filling out this form you are consenting to make this information available to the public through the Source Directory. Please only include information that you wish to make available to the public.
Paperwork Reduction Act Statement: This information is collected to identify and revise listings for the Source Directory of American Indian and Alaska Native owned and operated arts and crafts businesses. The information is supplied by the respondent to obtain or retain a benefit, that is, inclusion in the Source Directory. It is estimated that responding to the request will take an average of 15 minutes to complete. This includes the amount of time it takes to gather the information and fill out the form. If you wish to make comments on the form, please send them to the Director, Indian Arts and Crafts Board, 1849 C Street N.W., MS 2528-MIB, Washington, D.C. 20240. Note: Comments, names and addresses of commentators are available for public review during regular business hours. If you wish us to withhold this information, you must state this prominently at the beginning of your comment. We will honor your request to the extent allowable by law. In compliance with the Paperwork Reduction Act of 1995, as amended, the collection has been reviewed by the Office of Management and Budget and assigned a control number and expiration date. The number and expiration date are at the top right corner of the form. Please note that an agency may not conduct or sponsor, and person is not required to respond to, a collection of information unless there is currently a valid OMB control number.
Notice: Penalty for
Misrepresentation It
is unlawful to offer or display for sale or sell any good, with or
For purposes of this law, the term ‘Indian’ means any
individual without
a Government trademark, in a manner that falsely (1) who is a
member of any Indian tribe, band, nation, Alaska suggests
it is Indian produced, and Indian product, or the product Native
village, or other organized group or community that is of
a particular Indian or Indian tribe or Indian arts and
crafts federally recognized, or
organization,
resident within the United States. An individual (2) who is a
member of any Indian group that has been formally who
knowingly violates this law is subject to a maximum fine
of recognized as an Indian tribe by a state legislature or by a
state $250,000
and/or imprisonment for five years. Corporations are commission
or similar organization legislatively vested with subject
to a maximum fine of $1,000,000. state tribal recognition
authority, or (3) who has been formally [18
U.S.C 1159] certified as an Indian artisan by an Indian tribe.
File Type | application/msword |
File Title | Indian Arts and Crafts Board |
Author | Jmoran |
Last Modified By | Alspach, David D |
File Modified | 2014-11-05 |
File Created | 2014-10-09 |