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f� <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> � <br /> SAN JOAQUIN COUNTY <br /> A <br /> r�ry„_y .G [/lilt SIIpQYVlSOYS <br /> 2. ? Donna K.Heran R.E.H.S. <br /> N �01 East Weber venue, Third Floor Carl Borgman,R.E.H.S. <br /> ` :• Director Mike Huggins,R.E.H.S., R.D.I. <br /> Al Olsen,R.E.H.S. Stockton. California 95202-2708 Douglas W. Wilson,R.E.H.S. <br /> C`gC,FORa�P Program Manager Telephone: (209) 468-3420 Margaret Lagorio, R.E.H.S. <br /> Laurie A.Cotulla,R.E.H.S. Robert i�IcClellon,R.E.H.S. <br /> Program Manager Fay: l_09) 464-013g <br /> Mark Barcellos, R.E.H.S. <br /> STATEMENT OF CITIZENSHIP, ALIENAGE, AND IMMIGRATION STATUS <br /> IN SUPPORT OF A REQUEST FOR STATE PUBLIC BENEFITS <br /> I A <br /> Print name of applicant(person who wants a license,certificate, or permit to operate) Yate <br /> Print name of person acting for applicant, if any: Relationship to Applicant <br /> Type of Application: PERMIT TO OPERATE EMPLOYEE HOUSING <br /> CITIZENSHIP/IMMIGRATION STATUS DECLARATION <br /> Citizens and nationals of the United States who meet all eligibility requirements may receive Occupational Licenses, Certificates, <br /> Approvals and/or Permits to Operate and must fill out SECTIONS A and D. <br /> Aliens who meet all eligibility requirements may also receive Occupational Licenses, Certificates,Approvals and/or Permits to Operate <br /> and must complete SECTIONS A, B, and D, and if necessary, SECTION C of this form. <br /> SECTION A: CITIZENSHIP/IMMIGRATION STATUS DECLARATION <br /> 1. Are you a citizen or national of the United States? Yes No <br /> If the answer to the above question is yes,where were your born? <br /> City/State/Country <br /> 2. To establish 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. IF YOU ARE AN ALIEN, <br /> PLEASE <br /> COMPLETE SECTION B,AND, IF 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 listed for each category are the most commonly used documents that the United States Immigration and Naturalization <br /> Service (INS)provides to aliens in those categories. You can provide other acceptable evidence of your alien status even if not listed <br /> below. <br /> An alien lawfully admitted for permanent residence under the Immigration and Naturalization Act(INA). Evidence includes: <br /> • INS Form 1-551 (Alien Registration Receipt Card,commonly known as a"green card"); or <br /> • Unexpired Temporary 1-551 stamp in foreign passport or on INS Form 1-94. <br /> An alien who is granted asylum under section 208 of the INA. Evidence includes: <br /> INS Form 1-94 annotated with stamp showing grant of asylum under section 208 of the INA; <br /> • INS Form 1-688B (Employment Authorization Card annotated"274a.1 2(a)(5)". <br /> • INS Form 1-766(Employment Authorization Document annotated"A5". <br /> Grant letter from the Asylum Office of INS:or <br /> • Order of an immigration judge-granting asylum. <br /> LC0001 <br /> 1 <br />