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State of Arizona
Department of Liquor Licenses and Control
800 W. Washington 5!" Floor
Phoenix, AZ 85007
(602) 542-5141
ARIZONA STATEMENT OF CITIZENSHIP
OR ALIEN STATUS FOR STATE PUBLIC BENEFITS
Title 1V of the federal Personal Responsibility and Work Opporiunity Reconciliation Act of 1996 (the "Act’}, B U.S.C. § 1621,
provides that, with cerloin exceplions, only United States cifizens, United States non-citizen nationals, non-exempt “qualified
dliens* [and sometimes only parliculor categories of qualified aliens}, nonimmigrant, and certain aliens paroled into the
United States are eligibie lo receive siale, or local public benefits. With certain exceptions. o professional license and
commercial license issued py a Staie agency is a State public benefit.
Arizona Revised Stalules § 41-1080 requires, in general, that o person applying for a license must subrait documentation io
ihe license agency thai satisfactorily demonstrales the applicant's presence in the Unifed States is authorized under federal
law.
Directions: All applicants must complete Sections |, ll, and {V. Applicants who are not U.S. citizens or natonals must also
complete Section ill.
Submit this completed form and o copy of one of more documeni{s) from fhe attached “Evidence of U,S. Citizenship, U.S.
National Status, or Allen Status" with your application for Ilcense or renewal. If ihe do ent you submit does nol contain.a
photograph, you must also provide a government Issued document thal contains your photograph, You must submit
supponiing legal documentalion (le. marrage certificate) If the name on your evidence Is not the same as your current
legal name.
__ SECTION |— APPLICANT INFORMATION
{. :
INDIVIDUAL OWNER/AGENT NAME (Print or type) Chae ona uc, ene
____ SECTION I~ CITIZENSHIP OR NATIONAL STATUS DECLARATION
Are you a cilizen or national of the United States? [Xlves (no
If Yes, indicoie place of birth:
a '
int] Aus, 4 Bey __.____Caunity or Tertiary CLaion, _
opy of a document from the aitached lisi
City_lhn pia State: for «
you answered Yes, 1} 0 Atlacr
2) Nor
Got
Lig at 128 |Gac}
Derk: vung ; C.
S uaar, Lic, arbors
— SECTION IV - DECLARATION |
All applicants must complete this section. .
i declare under penally of perjury under the laws of the stale of Arizona thol the answers and evidence | have given are
jrue ond correct to the best of my knowlecige.
_ Cho dona Le aa
Indiviztwat Owner/Agent Printed Name
ayia 7 ,
hed Wttlupaa bf /22.
iw Individual Qiener/Agent eee Today's Date
EVIDENCE OF U.S. CITIZENSHIP, U.S. NATIONAL STATUS, OR ALIEN STATUS
You must submit supporting legal documentation (i.e. manlage certificate) if the
name on your evidence Is not the some as your current legal name.
Evidence showing authorized presence In the United State Includes the following:
1 An Arizona driver license issued after 1996 or an Arizona non-operating identification card.
A driver license issued by o 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 January 13, 1941}, Guam, the U.S. Virgin Islands {on or after January 17, 1917),
American Somoa, of the Norlhem Mariana Islands (on or after November 4, 1986, Northern Mariana Islands
local time)
A United States cenlificate of birth abroad.
A United States passport. ***Passport must be signed***
A foreign passport with a United States visa.
Anl-94 form with a photograph.
A United States citizenship and immigration services employment authorization document or refugee travel
On ama
document
9 AUnited Siates certificate of naturalization. :
10. A United States certificate of citizenship. |
4). A tribal certificate of Incian blood, |
12. A tribal or bureay of Indian affoirs affidavit of birth.
13. Any other license thot is issued by the federal government, any other stale government, an agency of this
slate or a political subdivision of this state that requires proof of citizenship or lawful alien status before issuing
the license.
PTE Page J of 3
Indivkivols reauiéng ADA occommadations clease cali 16021542 9027
SECTION Ill - ALIEN STATUS DECLARATION
‘are not citizens or nationals of the United States. Please indicate alien status by
document from the attached list or other dacumen! os
To be completed by applicanis who
checking Ine appropriate box. Attach a legible copy of a
evidence of your siatus.
Name of document provided
Qualified Alien Status (8 U.S.C.§§ 1621(a)(1),-1641{b) and (c))
O 1. Analien lawtully admitled for permanent residence under the Immigration and Nationality Act (INA)
(2) 2. An alien who is granied asylum under Section 208 of the INA.
aa] 3. Arelugee admitted to the United States under Section 207 of the INA.
oO 4, Analien paroled into the United States tor at least one year under Seclion 212{d}{5) of the INA.
oO 5. Analien whose deportation is being withheld under Section 243(h) of the INA.
CO 6. Analien granted conditional entry under Section 203{a) (7) of the INA as in effect prior to April 1, 1980.
(117. An alien who is a Cubon/Haitian entrant.
Cs. An alien who has, or whose child or child's parent is a “battered alien” or an alien subject to extreme cruelly in
the United States.
Nonimmigrant Status (8 U.S.C. § 1621 (a)(2})
oO 9. A nonimmigrant under the Immigration and Nationality Act [8 U.S.C § 1101 et 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))
(io. anaiien paroled into the United States for less Ihan one year under Section 212(d}{5) of Ihe INA
Other Persons (8 U.S.C § 1621(c)(2)(A) and (C)
oO) 11. A nonimmigrant whose visa for entry is related to employment in the United States, or
oO 12. A citizen of a freely associated state, if section {41 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 Stales include the Republic
of the Marshal Islands, Republic of Palau and the Federate States of Micronesia, 48 US.C. § 1901 efseq.]:
O 3. A loreign national not physically present in the Uniled States.
Otherwise Lawtully Present
OO 14. A person noi described in caiegories t-13 who is otherwise lawfully present in ihe Uniled States.
PLEASE NOTE: The federal Personal Responstbility and Work Opportunity Reconciliation Act
may make persons who fall Into this category ineligible for licensure, See U.S.C. § 1421(a).
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Individuals reauiing ADA accommodations please call (6021542-902?