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{ PUBLIC HEALTH SERVICES QdU�u SAN JOAQUIN COUNTY Q '� ENVIRONMENTAL HEALTH DIVISION Karen Furst, M.D., M.P.H., Health Officer :. 304 East Weber Avenue, Third Floor • Stockton, CA 95202 4�lFo.R�i a 2091468-3420 STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION STATUS IN SUPPORT OF A REQUEST FOR STATE PUBLIC BENEFITS Print name of applicant(person who wants a liense,certificate, or permit to operate): Date: THOMAS SARALE JANUARY 7, 2002 [ Print name of person acting for applicant,if any-.-- Relationship to applicant-.----- Type pplicant-.---Type of Application: PERMIT TO OPERATE EMPLOYEE HOUSING 4 r CITIZENSHIPAMMIGRATION STATUS DECLARATION a Citizens and nationals of the United States who meet all eligibility requirements may receive Occupational Licenses, Certificates, Approvals and/or Permits to Operate and must fill out SECTIONS A and D. _ Aliens who meet all eligibility requirements may also receive Occupational Licenses, Certificates,Approvals and/or Permits to Operate i and must complete SECTIONS A, B, and D, and if necessary, SECTION C of this form. SECTION A:CITIZENSHIP/IMMIGRATION STATUS DECLARATION 1. Are you a citizen or national of the United States? Yes No If the answer to the above question is yes,where were your born? Stockton, Ca] i form 1 a-, USA City/State/Country 2. To establiifi.citizenshi_ or nationality, please submit a legible and Unaltered copy of one of-the-documents ori" A. 4m aaa IF YOU ARE A CITIZEN OR NATIONAL OF THE UNITED STATES, GO DIRECTLY TO SECTION D. IF YOU ARE AN ALIEN, PLEASE COMPLETE SECTION B,AND, IF NECESSARY, SECTION C. SECTION B: ALIEN STATUS DECLARATION IMPORTANT: Please indicate your 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. An alien lawfully admitted for permanent residence under the Immigration and Naturalization Act(INA). Evidence includes: • INS Form 1-551 (Alien Registration Receipt Card,commonly known as a"green card"); or • Unexpired Temporary 1-551 stamp in foreign passport or on INS Form 1-94. An alien who is granted asylum under section 208 of the INA. Evidence includes: • INS Form 1-94 annotated with stamp showing grant of asylum under section 208 of the INA; • INS Form 1-688B(Employment Authorization Card annotated"274a.12(a)(5)". • INS Form 1-766(Employment Authorization Document annotated"A5". • Grant letter from the Asylum Office of INS;or ♦ Order of an immigration judge-granting asylum. - m 1 1 LC0001 A Division of San Joaquin Counly health Care Services