Form E - Affidavit For Educational Training Certificate printable pdf download

Form E - Affidavit For Educational Training Certificate

Form E

O.C.G.A. § 50-36-1(e)(2) Affidavit for Educational Training Certificate

By executing this affidavit under oath, as an applicant for a ed u ca tio n al t r ain in g c ert ifi ca te, as referenced in

O.C.G.A. § 50-36-1, from the Georgia Composite Medical Board, the undersigned applicant verifies one of the following

with respect to my application for a public benefit:

I am a United States citizen.

I am a legal permanent resident of the United States.

I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act with an alien

number issued by the Department of Homeland Security or other federal immigration agency. My alien

number issued by the Department of Homeland Security or other federal immigration agency

is:

The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has provided at least one

secure and verifiable document, as required by O.C.G.A. § 50-36-1(e)(1), with this affidavit.

The secure and verifiable document provided with this affidavit can best be classified as:

In making the above representation under oath, I understand that any person who knowingly and willfully makes a false,

fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of O.C.G.A. § 16-10-20,

and face criminal penalties as allowed by such criminal statute.

Executed in

(city),

(state).

Signature of Applicant

Printed Name of Applicant - (Print legibly)

SUBSCRIBED AND SWORN

BEFORE ME ON THIS THE

DAY OF

, 20

NOTARY PUBLIC

My Commission Expires:

AFFIDAVIT OF APPLICANT

Form E - Affidavit For Educational Training Certificate