STATE OF CALIFORNIA ­ DEPARTMENT OF BUSINESS OVERSIGHT DBO­250.61 (Rev. 08-13) STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION STATUS Print Name of Applicant (the applicant is the individual who wants the license or certificate). Date Print Name of Person Acting for Applicant, if any. Relationship to Applicant LICENSES AND CERTIFICATES TO CITIZENS AND ALIENS Citizens and nationals of the United States who meet all eligibility requirements and apply for a license or certificate must fill out Sections A and D of this form. Aliens who meet all eligibility requirements and apply for a license or certificate must complete Sections A, B, C (if applicable), and D of this form. SECTION A: CITIZENSHIP/IMMIGRATION STATUS DECLARATION 1. Is the applicant a citizen or national of the United States? Yes ____ No ____ If the answer to the above question is "Yes", where was he/she born? _____________________________________________________________________ (City/State) 2. To establish citizenship or nationality, please submit one of the documents on List A (attached hereto), which must be legible and unaltered to establish proof. IF YOU ARE A CITIZEN OR NATIONAL OF THE UNITED STATES, PROCEED DIRECTLY TO SECTION D. IF YOU ARE AN ALIEN, PLEASE COMPLETE SECTION B, SECTION C (IF APPLICABLE), AND SECTION D. SECTION B: ALIEN STATUS DECLARATION IMPORTANT: Please indicate the applicant's alien status below, and submit documents evidencing such status. The alien status documents listed for each category are the most commonly used documents that the United States Immigration and Naturalization Service (INS) provides to aliens in those categories. You can provide other acceptable evidence of your alien status even if not listed below. 1. An alien lawfully admitted for permanent residence under the Immigration and Naturalization Act (INA). Evidence includes: · INS Form I-551 (Alien Registration Receipt Card, commonly known as a "green card"); or · Unexpired Temporary I-551 stamp in foreign passport or on INS Form I-94. [] American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA ­ DEPARTMENT OF BUSINESS OVERSIGHT DBO­250.61 (Rev. 08-13) Page 2 of 10 STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION STATUS 2. An alien who is granted asylum under Section 208 of the INA. Evidence includes: · INS Form I-94 annotated with stamp showing grant of asylum under Section 208 of the INA; · INS Form I-688B (Employment Authorization Card) annotated "274a.12(a)(5)"; · INS Form I-766 (Employment Authorization Document) annotated "A5"; · Grant letter from the Asylum Office of INS; or · Order of an immigration judge granting asylum. A refugee admitted to the United States under Section 207 of the INA. Evidence includes: · INS Form I-94 annotated with stamp showing admission under Section 207 of the INA; · INS Form I-688B (Employment Authorization Card) annotated "274a.12(a)(3)"; · INS Form I-766 (Employment Authorization Document) annotated "A3"; or · INS Form I-571 (Refugee Travel Document). An alien whose deportation is being withheld under Section 243(h) of the INA (as in effect immediately prior to September 30, 1996) or Section 241(b)(3) of such Act (as amended by Section 305(a) of Division C of Public Law 104-208). Evidence includes: · INS Form I-688B (Employment Authorization Card) annotated "274a.12(a)(10)"; · INS Form I-766 (Employment Authorization Document) annotated "A10"; or · Order from an immigration judge showing deportation withheld under Section 243(h) of the INA as in effect prior to April 1, 1997, or removal withheld under Section 241(b)(3) of the INA. An alien who is granted conditional entry under Section 203(a)(7) of the INA as in effect prior to April 1, 1980. Evidence includes: · INS Form I-94 with stamp showing admission under Section 203(a)(7) of the INA; · INS Form I-688B (Employment Authorization Card) annotated "274a.12(a)(3)"; or · INS Form I-766 (Employment Authorization Document) annotated "A3". An alien who is a Cuban or Haitian entrant (as defined in Section 501(e) of the Refugee Education Assistance Act of 1980). Evidence includes: · INS Form I-551 (Alien Registration Receipt Card, commonly known as a "green card") with the code CU6, CU7, or CH6; · Unexpired temporary I-551 stamp in foreign passport or on INS Form I-94 with the code CU6 or CU7; or · INS Form I-94 with stamp showing parole as "Cuban/Haitian [] 3. [] 4. [] 5. [] 6. [] American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA ­ DEPARTMENT OF BUSINESS OVERSIGHT DBO­250.61 (Rev. 08-13) Page 3 of 10 STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION STATUS Entrant" under Section 212(d)(5) of the INA. 7. An alien paroled into the United States for at least one year under Section 212(d)(5) of the INA. Evidence includes: · INS Form I-94 with stamp showing admission for at least one year under Section 212(d)(5) of the INA. (Applicant cannot aggregate periods of admission for less than one year to meet the one-year requirement.) An alien paroled into the United States for less than one year under Section 212(d)(5) of the INA. (Evidence includes INS Form I-94 showing this status.) An alien not in status categories 1 through 8 who has been admitted to the United States for a limited period of time (a non-immigrant). Non-immigrants are persons who have temporary status for a specific purpose. (Evidence includes INS Form I-94 showing this status.) [] 8. [] 9. [] SECTION C: DECLARATION FOR BATTERED ALIENS IMPORTANT: Complete this section if the applicant, the applicant's child or the applicant child's parent has been battered or subjected to extreme cruelty in the United States. 1. Has the INS or the EOIR granted a petition or application filed by or on behalf of the applicant, the applicant's child, or the applicant's child's parent under the INA or found that a pending petition sets forth a prima facie case? Evidence includes one of the documents on List B (attached hereto). Has the applicant, the applicant's child, or the applicant child's parent been battered or subjected to extreme cruelty in the United States by a spouse or parent, or by a spouse's or parent's family member living in the same house (where the spouse or parent consented to, or acquiesced in the battery or cruelty)? [] 2. [] SECTION D: I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE ANSWERS I HAVE GIVEN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. Applicant's Signature: ____________________________ Da