diff --git a/src/registrar/templates/application_tribal_government.html b/src/registrar/templates/application_tribal_government.html
new file mode 100644
index 000000000..48eb79f18
--- /dev/null
+++ b/src/registrar/templates/application_tribal_government.html
@@ -0,0 +1,29 @@
+{% extends 'application_form.html' %}
+{% load field_helpers %}
+
+
+{% block form_fields %}
+
+  {% with sublabel_text="Please include the entire name of your tribe as recognized by the Bureau of Indian Affairs." %}
+    {% with link_text="Bureau of Indian Affairs" %}
+      {% with link_href="https://www.federalregister.gov/documents/2023/01/12/2023-00504/indian-entities-recognized-by-and-eligible-to-receive-services-from-the-united-states-bureau-of" %}
+        {% with class="usa-link usa-link--external" %}
+          {% with rel="noopener noreferrer" %}
+            {% with target_blank="true" %}
+              {% input_with_errors forms.0.tribe_name %}
+            {% endwith %}
+          {% endwith %}
+        {% endwith %}
+      {% endwith %}
+    {% endwith %}
+  {% endwith %}
+
+  <fieldset class="usa-fieldset">
+    <legend class="usa-legend">
+      <p>Is your organization a federally-recognized tribe or a state-recognized tribe? Check all that apply.
+      <abbr class="usa-hint usa-hint--required" title="required">*</abbr></p>
+    </legend>
+    {% input_with_errors forms.0.federally_recognized_tribe %}
+    {% input_with_errors forms.0.state_recognized_tribe %}
+  </fieldset>
+{% endblock %}