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���J�7lK������ �Jr�� � ��D� 8Kr��� w ������ ��'������J�� <br /> ' ^ ��l� � Jk����l������� ����� ]HEALTH ����� ��u��� ������� � �� <br /> 42 � �� D�� � ���T��� �����T������ <br /> x���n COUNTY`����� ~V���u�� Unit Supervisors <br /> D^»»» K' Bcran' R.E''U.5' 304Eu6tlAleber A^onuc,Third Floor Carl Borgmxn.K.E.8.8. <br /> Director4ikc Rus_,Li»`� K.E.H�^ R.D.I. <br /> At 0 ornig ' 708 <br /> ' �2B �[oc�k)n' -�ifa ���� � <br /> Doug)zov{ xl\mn. K.E.R.5. <br /> �n� ���'' �\c��c� ���)4�'�420 Hz/� <br /> r � x�tL�o�.Q.E.H.S. <br /> i��T' Laurie A. CotuUu. R'E'B.3. Fu (2 �| 4�4-U)�� D^not McC\cUon. R.E.R.S. <br /> yn�nox um/uxv, � �cK[unu�,n� D E H S <br /> ��:���hc�xun�g�o`�Or� '`�.! � � � . <br /> STATEMENT OF CITIZENSHIP, ALIENAGE AND |01K8(GRAT|C)N STATUS <br /> IN SUPPORT OF A REQUEST FOR STATE PUBLIC BENEFITS <br /> —Scf-f <br /> Print name of applicant(person who wants a license,certificate, or permit to operate) 15ate <br /> Print name of persor -,ting for applicant, if an'y: - Relationship to Applicant <br /> Type of Application: P�_'<K8|TTO OPERATE EMPLOYEE HOUSING <br /> CmZsN8H\P/|K0K8|GRAT|ON STATUS DECLARATION <br /> Citizens and nationals of the United States who meet all eligibility requirements may receive Occupational Licenses, Certificates, <br /> Appmxa!u and/or Permits to OpoxoVs and must fill out SECTIONS Aand D. <br /> Aliens who meet all eligibility requirements may also receive Occupational Liconoau, Certificates,Approvals and/or Permits to Operate <br /> and must complete SECTIONS A. 8.and D. and if necessary, SECTION C of this form. <br /> SECT|ONA: CITIZEN SH|P/|K8KO|G RATION STATUS DECLARATION <br /> 1 Are you a citizen o/national of the United States? No <br /> |fp`e anovvertnthe above question ioyoo.vvhoroworoyou/born? <br /> 2 To esta..lsh citizenship or nationality please submit a legible and unaltered copy of one of the documents on List A. <br /> IF YOU ARE A CITIZEN OR NATIONAL OF THE UNITED STATES,GO DIRECTLY TO SECTION D. !F YOU ARE ANALIEN, <br /> PLEASE <br /> COMPLETE SECT}Or. B.AND, |F NECESSARY, SECTION C. <br /> SECTION B; ALIEN STATUS DECLARATION <br /> IMPORTANT: Please indicate your alien status below,and submit documents evidencing such status. The alien status <br /> documents|i^Vod for each category are the most commonly used documents that the United States Immigration and Nah/no|izaVn n <br /> Service (|N5) pmvidoo to aliens in those categories. You can provide other acceptable evidence of your alien status even if not list <br /> ed <br /> below. <br /> An alien lawfully admitted for permanent residence under the Immigration and Naturalization Act(|NA). Evidence includes: <br /> ' ° INS Form 1'551 (Alien Registration Receipt Card,commonly known aoo"green oundl;or <br /> ° Unexpired Temporary 1'551 stamp in foreign passport u/un INS Form 1'Q4. <br /> An alien who is granted asylum under section 208 of the |NA. Evidence includes: <br /> ° INS Form 1-94 annotated with stamp showing grant of asylum under section 208 of the INA; <br /> ° ' INS Form 1'G88B(Employment Authorization Card annotated^274o.12(u)(5)". <br /> INS Form 1-7O0(Employment Authorization Document annotated"W <br /> ° ' Grant letter from the Asylum Office nf INS;or <br /> ° Order o[an immigration judge-granting asylum. <br /> LC0O01 <br />