Indian Arts & Crafts Board Source Directory Form

I

OMB #: 1085-0001

Expires: XX/XX/2018

ndian Arts and Crafts Board

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.