Form N-300 - Application To File Declaration Of Intention Page 2
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Part 1. Information About You (continued)
A-
10.
Mailing Address
In Care Of Name (if any)
Street Number and Name
Apt.
Ste.
Flr. Number
City or Town
State
ZIP Code
11. Physical Address
Street Number and Name (do not provide a PO Box in this space unless it is your ONLY address)
Apt.
Ste.
Flr. Number
City or Town
State
ZIP Code
Part 2. Applicant's Statement, Contact Information, Certification, and Signature
NOTE: Read the Penalties section of the Form N-300 Instructions before completing this part. You must file Form N-300 while in
the United States.
Applicant's Statement
NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1.
Applicant's Statement Regarding the Interpreter
A.
I can read and understand English, and I have read and understand every question and instruction on this application and
my answer to every question.
B.
The interpreter named in Part 3. read to me every question and instruction on this application and my answer to every
question in
, a language in which I am
fluent and I understood everything.
2.
Applicant's Statement Regarding the Preparer
At my request, the preparer named in Part 4.,
,
prepared this application for me based only upon information I provided or authorized.
Applicant's Contact Information
3.
Applicant's Daytime Telephone Number
4.
Applicant's Mobile Telephone Number (if any)
5.
Applicant's Email Address (if any)
Form N-300 12/23/16 N
Page 2 of 8
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