Verification Of U.s. Citizenship Form
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USCG AUXILIARY/SECCEN
Verification of U.S. Citizenship
Section 1. Prospective Member or Current Member Information
Print Name: Last
First
M.I.
Maiden Name
Address (Street Name and Number)
Apt. #
Date of Birth (month/date/year)
|
|
City
State
Zip Code
Social Security #
I attest that I am (check one of the following):
A U.S. citizen or national by birth in the U.S. or U.S. territory/possession.
A U.S. citizen, but was not born in the U.S.
I understand that any false statement contained herein is grounds for my disenrollment
from the U.S. Coast Guard Auxiliary.
Signature of Prospective Member or Current Member
Printed Name
Date
Section 2. Auxiliary Officer Review and Verification
(To be completed and signed by an existing Auxiliary Officer/Authorized Representative. Examine one of the original
documents listed and checked below. Then record the required information, if any, of the document.)
Birth Certificate showing that you were born in the United States of America
FS-240 (Report of Birth Abroad of a Citizen of the United States)
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Month/Day/Year__________________ Explanation__________________________________________
FS-545 (Certificate of Birth-Foreign Service)
DS-1350 (Certificate of Birth issued by U.S. Department of State)
A United States Passport (unexpired or expired)
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Passport Number__________________ Month/Day/Year Issued_________________________________
A Certificate of U.S. Citizenship (INS Form N-560 or N-561) Where Issued?
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City _______________________State_______Certificate #________________M/D/Yr______________
A Certificate of Naturalization (INS Form N-550 or N-570) Where Naturalized?
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Court_______________City___________State_______Certificate #_______________M/D/Yr________
CERTIFICATION- I attest that I have examined the document presented by the above-named prospective
or current member, that the above checked document appears to be genuine and to relate to the prospective
or current member named, thus does qualify for membership in the USCG Auxiliary.
Signature of Auxiliary Officer/Authorized Representative Verifying Document
Date
Print Name of Auxiliary Officer/Authorized Representative Verifying Document
RAS 11/12/2004
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