Form BIA 4432
Form BIA 4432
Form BIA 4432
To establish eligibility for Indian preference for employment with BIA/HIS. Complete one of the
Categories below and submit with your OF-612, Option Application for federal Employment.
Category
A
Date of Birth
Tribal Affiliation
I certify that the above information was taken from the official membership records of the
____________________ Tribe and acknowledge that falsification and misrepresentation of this
information is punishable under Federal Law.
_________________________ ___________ OR _________________________ ___________
Tribal Representative
Date
BIA Representative
Date
_________________________
______________________________________
Title
Title
______________________________________
Agency Name
Category
B
_________________________ ___________
Name of Individual
Date of Birth
_______________________________________
Reservation of Residence on June 1, 1934
________________________________
_______________________________________
Ancestor
_____________
Date
_______________________________________
BIA Representative
_______________________________________
Title
_______________________________________
Agency Name
Category
C
Date of Birth
Based On:
______________________________________ ________________________________ ___________
______________________________________ BIA Representative
Date
______________________________________ _____________________________________________
______________________________________ Title
Name Records
Category
D
___________________________________________________ ______
Agency
__________ ______________________________________
Date of Birth
_______________________________________________________________
Record on Which Based
__________________________________ ______________
BIA Representative
Date
__________________________________________________
Title
__________________________________________________
Agency
Paternal Grandfather
Father
Paternal Grandmother
Applicant
Maternal Grandfather
Mother
Maternal Grandmother
Great-Great Grandfather
Great Grandfather
Great-Great Grandmother
Paternal Grandfather
Great-Great Grandfather
Great Grandmother
Great-Great Grandmother
Great-Great Grandfather
Great Grandfather
Great-Great Grandmother
Paternal Grandmother
Great-Great Grandfather
Great Grandmother
Great-Great Grandmother
Great-Great Grandfather
Great Grandfather
Great-Great Grandmother
Maternal Grandfather
Great-Great Grandfather
Great Grandmother
Great-Great Grandmother
Great-Great Grandfather
Great Grandfather
Great-Great Grandmother
Maternal Grandmother
Great-Great Grandfather
Great Grandmother
Great-Great Grandmother