Verification Of Residency Form - Georgia Department Of Public Health printable pdf download

Verification Of Residency Form - Georgia Department Of Public Health

Brenda Fitzgerald, MD, Commissioner | Nathan Deal, Governor

2 Peachtree Street NW, 13th Floor

Atlanta, Georgia 30303-3142

Georgia Department of Public Health

GEORGIA DEPARTMENT OF PUBLIC HEALTH

Verification of Residency

In order to obtain and/or renew my status as an Approved Soil Classifier, I hereby swear, under oath, that I am:

(check one of the following)

_______A Citizen of the United States;

_______A legal permanent resident of the United States;

_______A qualified alien or non-immigrant under the Federal Immigration and Nationality Act.

Official Alien Number: ___________

I also swear that I am eighteen years of age or older, and that I have provided a least one secure and verifiable

identity document with this affidavit, as required by O.C.G.A. Section 50-36-1(e)(1).

Copy of document provided (check one):

_______Driver’s license

_______Birth certificate

_______US Passport

_______US Permanent Residence or Alien Registration Receipt Card

_______Certificate of Citizenship or Naturalization

_______Other (please call our office at 404-657-6534 to verify document will be accepted)

In making these representations, I understand that any person who knowingly and willfully makes a false

statement in an affidavit on any matter within the jurisdiction of state government shall be guilty of a violation

of O.C.G.A. Section 16-10-20 and face the criminal penalties authorized by that statute.

Subscribed and sworn before me

Contractor Name (printed):

this _____ day of _______________, 20____.

_______________________________________________

Contractor Signature:

_________________________________________

_______________________________________________

Notary Public

My commission expires ________________.

New

Renewal

(circle one)

Current Certification # (required for all renewals):

______________________

Note:

This form must be notarized and stamped or it

will not be accepted. A separate copy of this form must

be submitted for each individual classifier, along with

the identification document.

Verification Of Residency Form - Georgia Department Of Public Health