Ab-0116 - Declaration Of Citizenship
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1
2STATE OF TENNESSEE
ALCOHOLIC BEVERAGE COMMISSION
Davy Crockett Tower
One Commerce Square
rd
500 James Robertson Parkway, 3
Floor
40 South Main Street
Nashville, TN 37243
4th Floor, Suite 415
615-741-1602
Memphis TN 38103
901-543-7284
4420 Whittle Springs Road
540 McCallie Avenue, Suite 341
Knoxville, TN 37917
Chattanooga, TN 37402-2055
865-594-6342
423-634-6434
DECLARATION OF CITIZENSHIP
MUST ACCOMPANY ALL APPLICATIONS FOR INITIAL LICENSING
The “SAVE Act” requires every state government entity, to verify that every adult applicant for a professional license is either
a U.S. citizen, a “qualified alien,” or a nonimmigrant who meets the requirements set out at 8 U.S.C. 1621.
I am applying for a ________________________________________license/permit.
_____________________
TYPE OF LICENSE/PERMIT (Please Print)
License Number if applicable
Name of establishment / company_______________________________________________________________________________
Please Print Legibly
Name: ___________________________________________________________________________________________
Last
First
Middle
Maiden
Mailing Address: __________________________________________________________________________________
Phone Number: Home: (_____) ______-________ Office: (_____) ______-_______ Fax: (______) ______-________
I am a United States Citizen:
_______Yes
_______No
Applicants Claiming United States Citizenship MUST provide a copy of two (2) or more of the following:
Tennessee Driver’s License, or photo ID issued by Department of Homeland Security.
1.
2.
A valid driver license or ID issued by another state provided its issuance requirements meet Department of
Homeland Security criteria.
3.
An official birth certificate issued by a U.S. state, territory, or other jurisdiction. Puerto Rican birth
certificates issued before July 1, 2010 do not count.
4.
A federally issued birth certificate.
5.
A valid, unexpired U.S. passport.
6.
A report of birth abroad of a U.S. citizen.
7.
A certificate of citizenship.
8.
A certificate of naturalization.
9.
A U.S. citizen ID card.
Any successor document to #’s 4-9 above.
10.
11.
SSN that the entity may verify with the Social Security Administration in accordance with Federal Law.
If you checked “No” please indicate from the list below which category applies to you:
_______ Permanent Resident
_______ A nonimmigrant applicant for a professional or commercial license whose visa for entry into the United
States is related to such employment
_______ A nonimmigrant under the Immigration and Nationality Act (8 U.S.C. 1101 et seq.).
______
Foreign nationals not present in the United States seeking the issuance or renewal of a professional license.
*Applicants claiming such status shall provide sufficient proof of foreign residency.
_______ Asylees who meet the qualifications set out in 8 U.S.C. 1158
AB-0116 (rev 5/15)
RDA 2116
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