Affidavit Re: Personal Identification For Licensure/registration printable pdf download

Affidavit Re: Personal Identification For Licensure/registration

STATE OF GEORGIA

)

) AFFIDAVIT RE: PERSONAL IDENTIFICATION

COUNTY OF____________ )

FOR LICENSURE/REGISTRATION

PERSONALLY APPEARED before the undersigned officer, duly authorized to

administer oaths, came the undersigned, who after having been duly sworn, states under

oath the following:

1. That my name is _____________________and that I am who I say I am;

2. That my address is ____________________________________________;

3. That I have presented sufficient identification to the notary that is true and

accurate;

4. That I am legally in the United States of America;

5. That I am applying to the Georgia Department of Human Services, Office of

Residential Child Care, to operate a business/activity to be located at the

following address: __________________________________________________

that subject to regulation by the Department of Human Services and that this

affidavit is a material part of the application; and

6. That if the Department subsequently determines that the material information

contained in this affidavit is false, I will be in violation of licensing/registration

requirements, which may result in revocation of my license or registration or

denial of my application for licensure.

Sworn to and subscribed before me )

This _____ day of ______, ______ )

)

)_________________________

)

Affiant

____________________________ )

NOTARY PUBLIC

)

STATE OF GEORGIA

)

My commission expires: _________.

Affidavit Re: Personal Identification For Licensure/registration