Shareholder Request Form

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341 W. Tudor Rd. STE 204
Anchorage, AK 99503
907-222-6900/office 907-222-6955/fax
SHAREHOLDER RECORD INFORMATION REQUEST FORM
The following information is needed to complete your Leisnoi Inc. Shareholder Record. Please
complete and return at your earliest convenience.
Full Legal Name: _____________________________________ SS#: ______-______-______
Maiden Name ____________________________________ Male _______ Female ___________
Address:______________________________________________________________________
Date of Birth: ____________________________________ Email: ________________________
Phone No: (H)_______________________________ (W) ______________________________
Are you Alaska Native (1/4 Blood Quantum or more)?
______ Yes
____
No
Are you a descendant of an Alaska Native?
______ Yes
____
No
Are you enrolled to a Native Corporation?
______ Yes
____
No
If Yes, Which Native Corporation? _________________________________________________
If you have any questions, you can contact 907-222-6900.
Signed: _____________________________________
Dated: _____________________
Gifted from: __________________________ or Estate of: ____________________________
Number of Shares to be received and or transferred: ________ Date: ____________________
Shareholder Request Form
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