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Form 250.61 - Statement Of Citizenship, Alienage, And Immigration Status For Application Of Department Of Corporations License Or Certificate

STATE OF CALIFORNIA

DEPARTMENT OF CORPORATIONS

STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION STATUS

FOR APPLICATION OF DEPARTMENT OF CORPORATIONS

LICENSE OR CERTIFICATE

Print Name of Applicant (the applicant is the individual who wants the license or certificate).

Date

Print Name of Person Acting for Applicant, if any.

Relationship to Applicant

LICENSES AND CERTIFICATES TO CITIZENS AND ALIENS

Citizens and nationals of the United States who meet all eligibility requirements and apply for a

license or certificate must fill out Sections A and D of this form.

Aliens who meet all eligibility requirements and apply for a license or certificate must complete

Sections A, B, C (if applicable), and D of this form.

SECTION A: CITIZENSHIP/IMMIGRATION STATUS DECLARATION

Is the applicant a citizen or national of the United States?

Yes ____ No ____

If the answer to the above question is "Yes", where was he/she born?

_____________________________________________________________________

(City/State)

To establish citizenship or nationality, please submit one of the documents on List A

(attached hereto), which must be legible and unaltered to establish proof.

IF YOU ARE A CITIZEN OR NATIONAL OF THE UNITED STATES, PROCEED DIRECTLY TO

SECTION D. IF YOU ARE AN ALIEN, PLEASE COMPLETE SECTION B, SECTION C (IF

APPLICABLE), AND SECTION D.

SECTION B: ALIEN STATUS DECLARATION

IMPORTANT: Please indicate the applicant's alien status below, and submit documents

evidencing such status. The alien status documents listed for each category are the most

commonly used documents that the United States Immigration and Naturalization Service

(INS) provides to aliens in those categories. You can provide other acceptable evidence of

your alien status even if not listed below.

An alien lawfully admitted for permanent residence under the

[ ]

Immigration and Naturalization Act (INA). Evidence includes:

•

INS Form I-551 (Alien Registration Receipt Card, commonly

known as a "green card"); or

•

Unexpired Temporary I-551 stamp in foreign passport or on INS

Form I-94.

250.61 (7/98)

Form 250.61 - Statement Of Citizenship, Alienage, And Immigration Status For Application Of Department Of Corporations License Or Certificate