PRINT NAME
Date ________________________________
Name_____________________________________________________________________...
of 1

Naaip member assistance form 1

Published on: Mar 3, 2016
Source: www.slideshare.net


Transcripts - Naaip member assistance form 1

  • 1. PRINT NAME Date ________________________________ Name____________________________________________________________________________ Age _______ Address______________________________________________________________________________________ Phone Number ___________________________ Additional Number if Applicable__________________________ Email_________________________________________ Website________________________________________ (Check One) I am an Individual I am part or representative of an organization Briefly explain why you are filing a complaint: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ I, ________________________________________________, grant authority to NAAIP to file claims on my behalf, seek remedy for abuses committed against me, seek the advice of legal counsel, secure medical care, housing, and other provisions on my behalf, which may be required to provide remedy for my particular issue, situation or claim. I understand that the NAAIP does not provide legal advice, but offers assistance at no cost to me. All arrangements made with lawyers and other entities shall be at my sole discretion and choosing. In the event of any lawsuit, medical claims or any other claims or awards received by me through any action of NAAIP, it is understood that I owe no monetary fees, proceeds or obligations to NAAIP. If NAAIP Representatives or Associates find conclusively that I have not told the truth concerning my complaint, NAAIP will terminate its assistance immediately and all documentation or tangible things shall be returned to you and the original owner(s). Signature of Applicant: ______________________________________________ Date____________________________ Signature of NAAIP Authorized Representative: ___________________________________________ Witness___________________________________________ MEMBER ASSISTANCE FORM National Association for the Advancement of Indigenous People

Related Documents