REDACTED PENDING JOB 350784_Redacted.pdf

Received in the Buckeye City Clerk's office June 17, 2025 at 4:41 p.m. by LCA

State of Arizona

Department of Liquor Licenses and Control

Created 06/17/2025 @ 01:08:33 PM
Local Governing Body Report

LICENSE
Number: Type: 012 RESTAURANT
Name: MONROE'S KITCHEN
State: Pending
Issue Date: Expiration Date:

Original Issue Date:
Location:

416 E MONROE AVENUE
BUCKEYE, AZ 85326

USA
Mailing Address:
Alt. Phone:
Emai: eS
AGENT
Name: MARIA DE LOS ANGELES ANAYA
Gender: Female
Correspondence Address: 416 EMONROE AVENUE
BUCKEYE, AZ 85326
USA
Phone:

Alt. Phone:
Email:

OWNER

Name:

Contact Name:

Type:

AZ CC File Number:
Incorporation Date:
Correspondence Address:

Phone:
Alt. Phone:
Email:

MONROE'S KITCHEN LLC bo OQ
MARIA DE LOS ANGELES ANAYA th |G
LIMITED LIABILITY COMPANY

23797166 State of Incorporation: AZ
03/07/2025

BUCKEYE, AZ 85326

USA

Page | of 2

APPLICATION INFORMATION

Application Number: 350784

Application Type: New Application ava w//
Created Date: 06/10/2025

QUESTIONS & ANSWERS

012 Restaurant

1)

2)

3)

4)

5)

6)

7)

8)

9)

Are you applying for an Interim Permit (INP)?
No
Are you one of the following? Please indicate below.
Property Tenant
Subtenant
Property Owner
Property Purchaser
Property Management Company
TENANT
Is there a penalty if lease is not fulfilled?
‘Yes
What is the penalty?
$86,407.50
Is the Business located within the incorporated limits of the city or town of which it is located?
Yes
What is the total money borrowed for the business not including the lease?
Please list each amount owed to lenders/individuals.
0
Are there walk-up or drive-through windows on the premises?
No
Does the establishment have a patio?
‘Yes
Is the patio contiguous or non-contiguous (within 30 feet)?
CONTIGUOUS
Is your licensed premises now closed due to construction, renovation or redesign or rebuild?
No
What type of business will this license be used for?
RESTAURANT

Page 2 of 2

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Buckeye, AZ 85326

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Monroe’s Kitchen
416 Monroe Avenue
Buckeye, AZ 85326

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RESTAURANT/HOTEL/MOTEL

OPERATION PLAN

Arizona Dept. of Liquor Licenses and Control
800 W. Washington St. 5 Floor Phoenix, AZ 85007
(602) 542-5141

Type or Print with Black Ink

' .
1. Name of restaurant {Please print): Monroe's Kitchen

2. Must indicate the equipment below by Make, Model, and Capacity:

LIST ONLY THE FOLLOWING - NO ATTACHMENTS
Falcon, AEG-24 624 Sq In(20 -30 Burgers) and Falcon, AEG-16 Sq In (8 - 10 Burgers)

Grill

Oven Elite Kitchen Supply, EO0162P, 2720 Cu In (2-4 Pizzas)
Freezer Dukers, D55AF, 40.74 Cu Ft

Refrigerator BOHN, ADTO700F, 264 Cu Ft

Sink Falcon, E3C-18X18-2-18, 47.37 Gallons
Dish Washing Facilities Sink & Garbage Disposal 22 Sq Ft

Food Pi tion Count

Foes on onl | 4x2.5 Ft, 4x1 Ft and 4x1.5 ft

Other Falcon Gas Range, AR 36-6, 1,170 Sq In 6 Burners

3. Attach a copy of your FULL menu with pricing INCLUDING NON-ALCOHOLIC BEVERAGES

4. What percentage of your public premises is used primarily for restaurant dining?

100

(Do not include kitchen, bar, hi-top tables, or game area.) %o

5. Does your restaurant have a bar area that is distinct and separate from the dining area? (yes No

(ILyes, what percentage of the public floor space does this area cover?) 0 Se
6. List the seating capacity for:
a) Restaurant dining area of your premises: [ 45 ]

(DO NOT INCLUDE PATIO SEATING)
b) Bar area { +__NWHEO

7/21/2022 Page 1 of 2
Individuals requiring ADA accommodations please call (602)542-2999

7. What type of dinnerware is primarily used in your restaurant? [Reusable O Disposable Both
8. Does your restaurant contain any games, televisions, or any other entertainment? | YES No

If yes, specify what types and how many (examples: 4-TV's, 2-Pool Tables, 1-Video Game, etc.)

9. Do you have live entertainment or dancing? | YES No
Ifyes, what type and how offen (example: DJ-2 x a week, Karaoke-2 x a month, Live Band-1 x a month, etc.)

10. List number of employees for each position:

Position How many
Cooks 1 ~
Bartenders 70 ( Wal peaform kat dukes)
Hostesses 2
managers (Bartender) [1], Will Server™
SIT FI
servers /(Bartender) 2) ~
Other { )
Other ( )
Other [ )

i na
1, (Print Full Name) Maria De Los Angeles Anaya hereby swear under penalty of perjury and in compliance

with A.R.S. § 4-210(A)(2) and (3) that | have read and understand the foregoing and yérify that the information and

statements that | have made herein are true and correct to the best of my knowl

Applicant Signature:

7/21/2022 Page 2 of 2
Individuals requiring ADA accommodations please call (602)542-2999

RECORDS REQUIRED

FOR AUDIT
RESTAURANT/HOTEL/MOTEL
Arizona Dept. of Liquor Licenses and Control

800 W. Washington St. 5" Floor Phoenix, AZ 85007
(602) 542-5141

Type or Print with Black Ink

In the event of an audit, you will be asked to provide to the Department any documents necessary to determine
Compliance with A.R.S. §4-205.02(G). Such documents requested may include however, are not limited to:

Monroe's Kitchen

1.Name of restaurant (Please print}:

2. All invoices and receipts for the purchase of food and spirituous liquor for the licensed premises.

3. A list of all food and liquor vendors

4. The restaurant menu used during the audit period

5. Aprice list for alcoholic beverages during the audit period

6. Mark-up figures on food and alcoholic products during the audit period

7. Arecent, accurate inventory of food and liquor (taken within two weeks of the Audit Interview Appointment)
8. Monthly Inventory Figures - beginning and ending figures for food and liquor

9. Chart of accounts (copy)

10. Financial Statements-Income Statements-Balance Sheets

11. General Ledger

A. Sales Joumals/Monthly Sales Schedules
1) Daily sales Reports (to include the name of each waitress/waiter, bartender, etc. with sales for that day)
2) Daily Cash Register Tapes - Journal Tapes and Z-tapes
3) Dated Guest Checks
4) Coupons/Specials/Discounts
5) Any other evidence to support income from food and liquor sales

B. Cash Receipts/Disbursement Journals

1) Daily Bank Deposit Slips

2) Bank Statements and canceled checks

12. Tax Records

A. Transaction Privilege Sales, Use and Severance Tax Return (copies)
B. Income Tax Return - city, state and federal (copies)

C. Any supporting books, records, schedules or documents used in preparation of tax returns

7/21/2022 Page 1 of 2
Individuals requiring ADA accommodations please call (602}542-2999

13, Payroll Records

A. Copies of all reports required by the State and Federal Government
B. Employee Log {A.R.S. §4-119)
C. Employee time cards (actual document used to sign in and out each work day)

D. Payroll records for all employees showing hours worked each week and hourly wages

14. Off-site Catering Records (must be complete and separate from restaurant records)

A. All documents which support the income derived from the sale of food off the license premises.
B. All documents which support purchases made for food to be sold off the licensed premises.

C. All coupons/specials/discounts

The sophistication of record keeping varies from establishment to establishment. Regardless of each licensee's
accounting methods, the amount of gross revenue derived from the sale of food and liquor must be substantially
documented.

REVOCATION OF YOUR LIQUOR LICENSE MAY OCCUR IF YOU FAIL TO COMPLY WITH
A.R.S. §4-210(A)7 AND A.R.S. §4-205.02(G).

A.R.S. §4-210(A)7

The licensee fails to keep for two years and make available to the department upon reasonable request all invoices,
records, bills or other papers and documents relating to the purchase, sale and delivery of spirituous liquors and, in
the case of a restaurant or hotel-motel licensee, all invoices, records, bills or other papers and documents relating to
the purchase, sale and delivery of food.

A.R.S. §4-205.02(G)

For the purpose of this section:

1. “Restaurant” means an establishment which derives at least forty percent (40%) of its gross revenue from the sale of food
2. "Gross revenue” means the revenue derived from all sales of food and spirituous liquor on the licensed premises regardless
of whether the sales of spirituous liquor are made under a restaurant license issued pursuant to this section or under any

under any other license that has been issued for the premises pursuant to this article.

Mari L na
1, (Print Full Name) ria De Los Angeles Anaya hereby swear under penalty of perjury and in compliance

with A.R.S. § 4-210(A)(2) and (3) that | have read and understand the foregoing and yerify that the information and

statements that | have made herein are true and correct to the best of my knowle

Applicant Signature:

*MAKE A IS DOCUMENT AND KEEP IT WITH RECORDS REQUIRED BY THE STATE*

7/21/2022 Page 2 of 2
Individuals requiring ADA accommodations please call (602)542-2999

MONROE’S KITCHEN

MENU

416 E. Monroe Ave. Buckeye, AZ 85326

BREAKFAST
Monday to Friday until 11:00 am. Saturday and Sunday until 2pm

*OMELETS* Served with hashbrowns and toast.

Meat lovers (3 eggs, chopped sausage, bacon, ham, chorizo & party cheese blend) ..
Veggie (3 Eges, mushroom, onion, tomato, bell pepper, spinach & party cheese blend)...
BYO Omelet (3 Eggs, party cheese blend, and 4 toppings) .....s.ssesesseesesceseeresseseeeeeesenseneeneren
Cheese Omelet (3 eggs & party cheese blend)......sssescessssesssrssecssuesccessuneeessnsneeessnnuussensnssessensnnneeseasnssate

*BREAKFAST BURRITOS* All burrito breakfasts are wrapped in a flour tortilla and served with
green or red salsa
© Meat lovers (3 eggs, chopped sausage, bacon, ham, chorizo & party cheese blend) wsesssesseseeee $16.99

e Veggie (3 Eggs, mushroom, onion, tomato, bell pepper, spinach & party cheese blend) ....
e BYO Burrito (3 Eggs, party cheese blend, and 4 toppings) ..........s+ssssseereseseseesseenesee

*PANCAKES/ TOAST* All pancake breakfasts are served with maple syrup and butter
e Pancake stack (Three traditional pancakes served with whipped butter & maple syrup)...
e Pancakes plate (Three pancakes, two sausage links or three pieces of bacon, and two eges
e The big one (2 pancakes, 2 eggs, 2 sausage links, 2 pieces of bacon, 1 piece of ham, hashbrowns, and1

biscuit and gravy)..... sariserosEseas
e French Toast re slices apnea with omen See
e French Toast plate (4 slices, 2 eggs, Choice Of Meat).........sessssneernneensrerssnsserecseresneeenetes
*BISCUITS*

e Biscuit and sausage gravy
e Biscuit plate (1 biscuit and gravy, two sausages or three pieces of bacon, and two eggs) ...

*EGGS* Served with hash browns and toast of choice

e¢ Two eggs (Sunnyside up, over easy, or scrambled) ... $10.99

e Meat and Eggs (2 Eggs and Ham, chorizo, bacon, or sausage) . $17.99

*LIGHT MEALS*

e Oatmeal (1 cup of oatmeal with brown sugar, cinnamon, cranberries, raisins & 2% milk) .......-........ $5.99

e Fruit and Yogurt Bowl (Strawberries, fresh-cut cantaloupe, grapes and low fat Vanilla Yogurt). . $9.99
Avocado toast (2 slices of white or wheat toast spread with avocado) 2 $5.49

e Avocado toast plate(2 slices of toast spread with avocado, 2 eggs and hash browns)... $12.49

*KIDS BREAKFAST* 12 Years old & under. All kids’ breakfasts are served with a cookie.

@ Pancake plate (1 pancake, 1 egg, and 1 link sausage or 1 bacon strip)
© Cup of Mac & Cheese .....
e Cup of Fruit (Strawberries, fresh-cut cantaloupe, grapes, vanilla yogurt and granla........-cevssseee- $6.99

*CONSUMING RAW OR UNDERCOOKED MEATS, POULTRY, SEAFOOD, SHELLFISH, OR EGGS MAY INCREASE RISK OFC FOODBORNE
ILLNESS, ESPECIALLY IF YOU HAVE MEDICAL CONDITIONS.

*SIDES*

Hashbrown6......-.scseeeeeeee $4.99 Extra Bacon (3)... $4.99
Rosemary potatoes......... Extra sausage (2)..............93.99
Bowl of Fruit... ! Green & Red salsa............9.50
Toast (2 slices) ... Gravy... $2.49
Extra cheese ... French Toast (2 slices).......$5.99
Slice Of HAM........esesseseseseee

Salads

Served all Day.

*SALADS* Add Chicken breast, Parmesan Chicken, or Shrimp

Caesar Salad (Romaine lettuce, Parmesan cheese, Crisp homemade croutons, and Caesar

LESSING) sesesssoscoscecsesososesessesssensessuevessorsncsnsectesssnenesseesoeaeeceererentsartensssssessesesassseanesnsaseceuecnstnenesnes $6.99
Garden Salad (Lettuce, carrots, cucumber, green onion, cherry tomatoes, and Italian

dressing) ..
Caprese Salad (Rich, juicy tomatoes layered with creamy, fresh white mozzarella cheese and sweet,
fragrant green basil leaves with balsamic glaze) $ 10.99
House Salad (Lettuce, red onion, tomatoes, and choice Of dreSsing) ...sssssssesererseeesecnesseneeneesees $6.99

Sandwiches
Served all Day.

*SANDWICHES**_All sandwiches are served with a bag of chips.

Ham & Swiss (Ham, Swiss, red onions, tomatoes, dill pickles, lettuce, and honey mustard)......... $12.99
Meatball panini (Meatballs in half evenly distributed on a bed of provolone cheese and focaccia

BPO A) cscarssssssssesesseccecesenssrececeseenssseseenetsseetentnneeeesennunanacecansuuassseesansscasnunasesseesenerececesausnenegqeonangnnaeinnansee $13.99
Grilled chicken caprese (sundried tomato, pesto, fresh mozzarella, grilled chicken, tomato, spinach,
and balsamic glaze, in focaccia Dread).......sssesssssseseseesessuseesersssssusssesesseesessnssnessscesstennauuesesceennannnontrsestsssasnssse $13.99

BLT (Bacon, lettuce, tomatoes, cheddar, mayo on toasted bread) ....
Grilled cheese (Swiss, brie, cheddar, arugula, and tomatoes) ,
Turkey and brie (Turkey breast, brie, roasted red peppers, lettuce, tomatoes, and grain

MUSEALA)......ccscsesescesesessvssessevsvevessesieseesissesseeceeeeecerteeteeeeecssenteeeciseerersesresreeeseseees B12,99

**Breads available: White, Wheat, Rye, Sourdough, and Focaccia.

*CONSUMING RAW OR UNDERCOOKED MEATS, POULTRY, SEAFOOD, SHELLFISH, OR EGGS MAY INCREASE RISK OFC FOODBORNE
ILLNESS, ESPECIALLY IF YOU HAVE MEDICAL CONDITIONS.

DINNER
Daily from 11:00 a.m. until 9:00 p.m.

* APETIZERS*

Garlic Bread (Garlic bread with a side of marinara) ...
Baked Meatballs (Two meatballs covered with marinara sauce, mozzarella cheese, and
parsley)
Burrata appetizer (Red tomatoes and basil chopped, over a garlic bread, topped with

balsamic glaze, and rich, creamy burrata CheeSe ..s.ssesesssesessescsesnetiesnsersaiesnensnsnenensnssiaesssnasenetstes $8.99

*PASTAS & SPECIALTIES * All pasta is accompanied by garlic bread.

Fettuccine or Penne, accompanied with your choice of sauce: Alfredo,

Pesto, OF Marinara ......sessssssssssssssesesssnsssssesessanosesssvessnsessenscsenesenneeeauiseesansessenonesaunecsnanete nesses: $13.99
Add Grilled Chicken breast, Parmesan Chicken, 2 meatballs
Add Shrimp( 8 pieces)..

Add Spinach, Mushrooms, Broccoli, or sundried tomato FOF ......s-ssessssessesssssnereesnnnees $2.99
e Chicken Parmigiana (Two lightly fried parmesan-breaded chicken breasts with our homemade
marinara and melted Italian cheeses. Served with a side of pasta) secssassaveeseerssessusunrenersessesesessseneenees L799
© Lemon Pepper Grilled Shrimp & Asparagus (Shrimp and asparagus grilled with butter
and lemon pepper seasoning, accompanied by mashed potatoes). seustsssisetsneee 918.99
*Flatbreads*
e Margherita (Pizza sauce, fresh white mozzarella cheese and sweet, fragrant green basil leaves with a

..$13.99

touch of balsamic glaze).
Meat Delight (sausage, chorizo, ham, pepperoni).
Pepperoni (pizza sauce, mozzarella cheese and pepperOni) ....-.-srssssseseeneeereeesnneeees $12.99
Veggies (pizza sauce, mozzarella cheese, spinach, peppers, onions, tomatoes, and

mushrooms). $13.99

*KIDS* 12 Years old & under. All kids’ plates are served with a cookie.

Kids’ fettuccine and meatball (Fettuccine pasta with 1 meatball covered with marinara)........99.99
Kids’ fettuccine Alfredo (Fettuccine Alfredo)...
Add Chicken for ...........
Cup of Mac & Cheese ..
Parmesan Chicken with a side of marinara or alfredo sauce (1 parmesan chicken cut into 4,

covered with marinara or alfredo sauce) .... sesssssssseessnseee 97-99

*Consuming raw or undercooked meat, poultry, seafood, shellfish, or eggs may increase the risk of

foodborne illness, especially if you have certain medical condition.

Drinks
Coffee (dark or with creamer of choice: French Vanilla, Hazelnut, or Regular) .
Tea (Sweet & UNSWeet)....e.ssssesssesssesssseesssesssneeneseninessnscssnesienssssnssessieecsnnsesanecennanennunseer anes
Milk (Whole or 2%)
Hot chocolate
Sodas (ask server for variety)....
Bottled Water

Tiramisu Cake .....----+2+0------+
New York Cheese Cake
Cupcakes

Piece of bread (ask server for variety)

* CONSUMING RAW OR UNDERCOOKED MEATS, POULTRY, SEAFOOD, SHELLFISH, OR EGGS MAY INCREASE THE RISK OF FOODBORNE
ILLNESS, ESPECIALLY IF YOU HAVE CERTAIN MEDICAL CONDITIONS.

DLLC USE ONLY

Arizona Dept. of Liquor Licenses and Control
https://www.azliquor.gov
(602) 542-5141

Fee:

Job #: Ss S O 71% Y
Date Accepted: b -\ oO “DS
CSR: WZ

FR Ppendi ne)
805-1038

Personal Information

Questionnaire

ATTENTION APPLICANT: This is a legally binding document. An investigation of your background will be conducted.

Incomplete applications will not be accepted. False or misleading answers may result in the denial or revocation
of a license or permit and could result in criminal prosecution.

THE COMPLETED QUESTIONNAIRE NEEDS TO BE SUBMITTED TO THE DEPARTMENT ALONG WITH A $22. FEE, AND FD-258 FINGERPRINT CARD,
THAT HAS BEEN SEALED IN AN ENVELOPE, AND SIGNED OR INITIALED BY THE FINGERPRINT TECHNICIAN, MUST INCLUDE THE FINGERPRINT
VERIFICATION FORM. MUST BE COMPLETED BY A RECOGNIZED FINGERPRINT SERVICE OR LAW ENFORCEMENT AGENCY.

Agent: a person who
is designated by an
applicant or licensee
to receive
communications from
the department and to
file and sign
documents submitted
to the department on
behalf of the applicant
or licensee. An agent
is not a manager.

AR.S. §4-202(A).

Controlling Person:
person directly or
indirectly possessing
control of an applicant
or licensee.

A.R.S. §4-101(10).

. Email address:

Home Address:

Manager: An
individual (not an
entity) approved by
the Department of
Liquor who has the
authority to organize,
direct, carry out,
control or to
otherwise operate the
day-to-day operations
of a liquor-licensed
business.

A.R.S. §4-101(22) and
A.R.S. §4-202(C)

. Liquor License #:
. Business Name (doing business as):

. Business Address:

6/21/2024

SECTION - 1 INDIVIDUAL INFORMATION

LJAGENT EACONTROLLING PERSON C1 MANAGER
. Name: Anaya Maria De Los Angeles
Last First Middle
. Social Security )|h|6UlU Birth bate: iii
(NOT a public record) (NOT a public record)
. Driver’s License ;§_ —— State Issued: Az

{NOT a public record)

. Are you a resident of Arizona? Yes CINo Date of residency: 98/01/2010

monroeskitchen.buckeye@gmail.com

. Daytime phone #: hh, hh Alternative phone #: |__|

SECTION 2 — LICENSED BUSINESS INFORMATION

Monroe's Kitchen

416 E. Monroe, Buckeye, AZ 85326

Page 1 of 2
Individuals requiring ADA accommodations please call (602)542-2999

SECTION 3 — DAY TO DAY OPERATION OF BUSINESS

Must attach copies of Basic and Management Title 4 training certificates for person managing the day to day
operation of the licensed business.

Who is managing the day to day operations? Elagent Ldcontrolling Person [Manager
Maria De Los AngelesAnaya

Name of persons who will be handling the day to day operations:

SECTION 4 — BACKGROUND

If you answer “YES” to any Question 1 through 5 YOU MUST attach a signed statement. Give complete details including
dates, agencies involved and dispositions. CHANGES TO QUESTIONS 1-5 MAY NOT BE ACCEPTED

1. Have you owned, or been a controlling person of any entities that held a liquor Yes [1 No
license in Arizona, or any jurisdiction, in the past 5 years?

2. Have you been cited, arrested, indicted, convicted, or required to appear in Yes O No
court for violation of ANY criminal law or ordinance, regardless of the
disposition, even if dismissed or expunged, within the past 5 years?

3. Has an entity in which you are or have been a controlling person had an Yes (J No
application or license rejected, denied, revoked, or suspended in or outside of
Arizona within the last 5 years? A.R.S.§4-202(D

4. Have you had ANY administrative law citations, compliance actions, or Yes No
consents, in any jurisdiction in the past 5 years? (Do not include civil traffic
tickets)

A.R.S.§4-202,4-210
*Administrative Law Violations are any civil penalties, fines, suspension,
or revocations of your liquor license.

5. Has anyone EVER obtained a judgement against you the subject of which Yes C1 No
involved fraud or misrepresentation?

Maria De Los Angeles Anaya

1, (Print Full Name) hereby swear under penalty of perjury and in

compliance with A.R.S. § 4-210(A)(2) and (3) that | have read and understand the foregoing and verify that
the information i, that | have made herein are true and correct to the best of my knowledge.

Ce

Signature: {
/

6/21/24 Page 2 of 2
Individuals requiring ADA accommodations please call (602)542-2999

ALLL, d Nasr sare, LUN 9, 2025

ALIEN STATUS

Arizona Dept. of Liquor Licenses and Control
800 W. Washington St. 5" Floor Phoenix, AZ 85007
(602) 542-5141

Type or Print with Black Ink

Title IV of the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (the "Act"), 8 U.S.C. §
1621, provides that, with certain exceptions, only United States citizens, United States non-citizen nationals, non-
exempt "qualified aliens" (and sometimes only particular categories of qualified aliens), nonimmigrant, and certain
aliens paroled into the United States are eligible to receive state, or local public benefits. With certain exceptions, a
professional license and commercial license issued by a State agency is a State public benefit.

Arizona Revised Statutes § 41-1080 requires, in general, that a person applying for a license must suomit
documentation to the license agency that satisfactorily demonstrates the applicant's presence in the United States
is authorized under federal law.

Directions: All applicants must complete Sections I, Il, and IV. Applicants who are not U.S. citizens or nationals
must also complete Section Ill.

Submit this completed form and a copy of one or more documeni(s) from the attached "Evidence of U.S. Citizenship,
U.S. National Status, or Alien Status" with your application for license or renewal. If the document you submit does not

contain a photograph, you must also provide a government issued document that contains your photograph. You
must submit supporting legal documentation (i.e. marriage certificate) if the name on your evidence is not the same

as your current legal name.

SECTION | — APPLICANT INFORMATION

Maria De Los Angeles Anaya

APPLICANT NAME (Print ortype)

SECTION II — CITIZENSHIP OR NATIONAL STATUS DECLARATION

Are you a citizen or national of the United States? Yes Cno - If yes, indicate place of birth:

_ Queretaro Queretaro Mexico
City State

COUNTRY

If you answered Yes, 1) Attach a legible copy of a document from the list below.

Arizona Drivers License

2) Nameof document:

If you answered No, you must complete Sections Ill.

7/21/2022 Page 1 of3
Individuals requiring ADA accommodations please call (602)542-2999

EVIDENCE OF U.S. CITIZENSHIP, U.S. NATIONAL STATUS, OR ALIEN STATUS

You must submit supporting legal documentation (i.e. marriage certificate) if the name on your evidence
is not the same as your current legal name.

Evidence showing authorized presence in the United State includes the following:

1.

10.

lis

2s

13.

7/21/2022

An Arizona driver license issued after 1996 or an Arizona non-operating identificationcard.

A driver license issued by a state that verifies lawful presence in the United States.

A birth certificate or delayed birth certificate showing birth in one of the 50 states, the District of
Columbia, Puerto Rico (on or after Jan. 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17,
1917), American Samoa, or the Northern Mariana Islands (on or after November 4, 1986, Northern
Mariana Islands local time)

A United States certificate of birth abroad.

A United States passport. ***Passport must be signed***

A foreign passport with a United States visa.

An I-94 form with a photograph.

A United States citizenship and immigration services employment authorization document or

refugee travel document.

A United States certificate of naturalization.

A United States certificate of citizenship.

A tribal certificate of Indian blood.

A tribal or bureau of Indian affairs affidavit of birth.

Any other license that is issued by the federal government, any other state government, an agency of

this state or a political subdivision of this state that requires proof of citizenship or lawful alien status

before issuing the license.

Page 2 of 3
Individuals requiring ADA accommodations please call (602)542-2999

SECTION III — QUALIFIED ALIEN DECLARATION

Applicants who are not citizens or nationals of the United States. Please indicate alien status by checking the
appropriate box. Attach a legible copy of a document from the attached list or other document as evidence
of your status.

Name of document provided

Qualified Alien Status (8 U.S.C.§§ 1621 (a)(1},-1641(b) and (c))

1. An alien lawfully admitted for permanent residence under the Immigration and Nationality Act (INA)
2. An alien who is granted asylum under Section 208 of the INA.

3. Arefugee admitted to the United States under Section 207 of the INA.

4  Analien paroled into the United States for at least one year under Section 212(d)(5) of the INA.

5. An alien whose deportation is being withheld under Section 243(h) of the INA.

6. An alien granted conditional entry under Section 203(a){7) of the INA as in effect prior to April 1, 1980.

. An alien who is a Cuban/Haitian entrant.

HDoOooudoagaoaoo

8. An alien who has, or whose child or child's parent is a "battered alien" or an alien subject to extreme

cruelty in the United States
Nonimmigrant Status (8 U.S.C. § 1621(a)}(2))

9. Anonimmigrant under the Immigration and Nationality Act [8 U.S.C § 1101 ef seq.] Non-immigrants
are persons who have temporary status for a specific purpose. See 8 U.S.C § 1101 (a)(15).

Alien Paroled into the United States for Less Than One Year (8 U.S.C. § 1621(a)(3))
10. An alien paroled into the United States for less than one year under Section 212(d) (5) of the INA

Other Persons (8 U.S.C § 1621(c)(2){A) and (C)

11. Anonimmigrant whose visa for entry is related to employment in the United States, or
12. A citizen of a freely associated state, if section 141 of the applicable compact of free association
approved in Public Law 99-239 or 99-658 (or a successor provision) is in effect [Freely Associated States

include the Republic of the Marshall Islands, Republic of Palau and the Federate States of Micronesia, 48
U.S.C. § 1901 etseq.];

13. A foreign national not physically present in the United States.

14. Otherwise Lawfully Present
15. A person not described in categories 1-13 who is otherwise lawfully present in the United States.

PLEASE NOTE: The federal Personal Responsibility and Work Oppgriunity Reconciliation Act may make persons who fall
into this category ineligible for licensure. See 8 U.S. §

Maria De Los Angeles Anaya
Print Name

June 9, 2025
Date

7/21/2022 Page 3 of 3
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