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FOR OFFICE USE ONLY
COVER SHEET
This is NOT an Application for Licensure or Renewal
For applications for licensure or renewal go to www.azbn.gov/applications
SENDER INFORMATION
Legal First Name
Middle Name
Legal Last Name
All Former Last Names
SSN
- -
Date of Birth / /
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CRNA
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LNA
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- -
C L P C S A
(If submitting an alien status
document on List B)
SIGNATURE - REQUIRED
Date
CNA
License/Certificate Number
Are you a citizen of the United States?
No Yes
If you answered "no" then you are required to complete &
submit the Alien Status Declaration
RN LPN AP
Type of Citizenship/Lawful Presence document provided: (Example: Birth Certificate, Passport, TN Visa)
Document Expiration Date
Type of Application (check one)
*If any of the following documents do not contain a photograph of the individual, the individual shall also present a
government issued document that contains a photograph of the individual.
NOTE: Licenses/certificates will not be issued until this sheet and a copy of the
documentation is received on 8½ x 11 sheet of paper.
Renewal Initial Exam Initial Endorsement
Type of License/Certification
Initial Advanced Practice
If you have not submitted your documentation of lawful presence with your application, attach a copy
of your lawful presence documentation to this cover sheet. If you are not a US citizen or national, you
must also submit a signed Alien Status Declaration. Faxes are not accepted
CITIZENSHIP/LAWFUL PRESENCE
Citizenship or Alien Status Declaration
□
Yes
□
No
If no go to ALIEN STATUS Declaration
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a.
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b.
□
c.
□
d.
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e.
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f.
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g.
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h.
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i.
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j.
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k.
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l.
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m.
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n.
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SIGNATURE - REQUIRED Date
Applicants who are NOT citizens or nationals MUST
Complete, Sign and SUBMIT this page with the Cover Sheet
Other Person (8 U.S.C. § 1621 (c)(2)(A) and (C))
Otherwise Lawfully Present (A.R.S. § 1-501)
To establish alien status, submit with your application a legible xeroxed copy of one of the documents from List B
.
Type of document you are submitting
Expiration Date, if any (mm/dd/yyyy)
A nonimmigrant whose visa for entry is related to employment in the United States.
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, 49 U.S.C. § 1901 et seq.];
A foreign national not physically present in the United States.
A person not described in categories A-M who is otherwise lawfully present in the United States. PLEASE NOTE: The
federal Personal Responsibility and Work Opportunity Reconciliation Act may make persons who fall into this category
ineligible for licensure.
A refugee admitted to the United States under Section 207 of the INA.
An alien paroled into the United States for at least on year under Section 212(d)(5) of the INA.
Type of document you are submitting (i.e. passport, birth certificate)
Expiration Date, if any (mm/dd/yyyy)
Are you a citizen of the United States?
An alien paroled into the United States for less than one year under Section 212(d)(5) of the INA.
Nonimmigrant Status (8 U.S.C. § 1621(a)(2))
Alien paroled into the United States for less than one year
(8 U.S.C. § 1621 (a)(3))
An alien who has, or whose child or child's parent has been declared a "battered alien" or an alien subjected to extreme cruelty
in the United States.
A nonimmigrant under the Immigration and Nationality Act [8 U.S.C. § 1101 et seq.] Nonimmigrants are persons who have
temporary status for a specific purpose. See U.S.C § 1101(a)(15).
If yes, submit with your application a legible xeroxed copy of your proof of citizenship document. Most often submitted is a
photocopy of a birth certificate or US passport. If you submit a copy of a birth certificate, please INCLUDE COPY of PHOTO
I.D. Social security cards are not accepted. To see a list of other accepted documents, visit www.azbn.gov/Citizenship
and click
on Citizenship and or Lawful Presence Cover Sheet/Alien Status Declaration/Lists A & B. If you have already submitted a proof
of citizenship/nationality document after 1/1/2008 you will not need to submit the document again.
An alien whose deportation is being withheld under section 243(h) of the INA.
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 and Haitian entrant (as defined in section 501(e) of the Refugee Education Assistance Act of 1980).
ALIEN STATUS DECLARATION
To be completed by applicants who are not citizens or nationals of the United States. Please indicate alien status by checking
the appropriate box. Submit a legible xeroxed copy of the front and back of a document from List B with your application. See
List B on our website by visiting www.azbn.gov/Citizenship
and click on "Citizenship and or Lawful Presence Cover
Sheet/Alien Status Declarations/Lists A & B.
"Qualified Alien" Status
An alien lawfully admitted for permanent residence under the Immigration and Nationality Act (INA).
An alien who is granted asylum under Section 208 of the INA.
ARIZONA STATEMENT OF CITIZENSHIP & ALIEN STATUS
All applicants must answer questions on the application regarding citizenship. A Xeroxed copy of a document that shows evidence
of your citizenship or alien status MUST BE submitted with your application for licensure or renewal. See List A or List B.
LIST A
Evidence showing U.S. citizen or U.S. national status includes the following:
*If any of the following documents do not contain a photograph of the individual, the individual shall also present
a
government is
sued document that contains a photograph of the individual.
a. Primary Evidence:
(1) An AZ driver’s license issued after 1996 or an AZ non-operating identification license
(2) A 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 Samoa, or the Northern Mariana Islands
(on or after November 4, 1986, Northern Mariana Islands local time) (unless the applicant was born to foreign diplomat
s
resid
ing in such a jurisdictio
n); *
(3
) A
birth certificate or delayed birth certificate issued in any state, territory or possession of the U.S.; *
(4) A signed United States passport; current or expired;
(5) Report of birth abroad of a U.S. citizen (FS-240) (issued by the Department of State to U.S. citizens); A U.S. certificate of
birth abroad *
(6) Certificate of Birth (FS-545) (issued by a foreign service post) or Certification of Report of Birth (DS-1350), cop
ies of
whi
ch are available from the Department of State;
*
(7) Form N-550 or N-570, Certificate of Naturalization (issued by the Service through a Federal or State court, or throug
h
adm
inistrative naturalization after December 1990 to individuals who are individually naturalized; the N-570 is
a
replacem
ent certificate issued when the N-550 has been lost or mutilated or the individual’s name has change
d);
(8)
Form N-561, Certificate of Citizenship;
(9) Form I-197, United States Citizen Identification Card (issued by the Service until April 7, 1983 to U.S. citizens living near
the Canadian or Mexican border who needed it for frequent border crossings) (formerly Form I-179, last issued in February
1974);
(10) Form I-873 (or prior versions), Northern Marianas Card (issued by the Service to a collectively naturalized U.S. citizen
who was born in the Northern Mariana Islands before November 3, 1986);
(11) Statem
ent provided by a U.S. consular official certifying that the individual is a U.S. citizen (given to an individual born
outside the United states who derives citizenship through a parent but does not have a FS-240, FS-545, or DS-1350); or *
(12) Form I-872 (or prior versions), American Indian Card with a classification code “KIC” and a statement on the back
identifying the bearer as a U.S. citizen (issued by the Service to U.S. citizen members of the Texas Band of Kickapoo
living near the U.S./Mexican bord
er).
(13)
A trib
al certificate of Indian
blood.*
(14)
A
tribal or bureau of Indian affairs affidavit of birth*
NOTE: SOCIAL SECURITY CARDS ARE NOT ACCEPTABLE DOCUMENTATION.
b. Secondar
y Ev
idence
If the applicant cannot present one of the documents listed in (a) above, the following may be relied upon to establish U.S.
citizenship or U.S. national status;
(1) Religious record recorded in one of the 50 states, the District of Columbia, Puerto Rico (on or after January 13, 1941)
,
G
uam, 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) (unless the applicant was born to foreign diplomats residing
in such a jurisdiction) within three 3 months after birth showing that the birth occurred in such jurisdiction and the date o
f
b
irth or the individual’s age at the time the record was m
ade;
(2) Evidence of civil service employment by the U.S. government before June 1, 1976;
(3) Early school records (preferably from the first school) showing the date of admission to the school, the applicant’s date
and
U.S.
place of birth, and the name(s) and place(s) of birth of the applicant’s parent(s
);
(4)
Census record showing name, U.S. nationality or a U.S. place of birth, and applicant’s date of birth or ag
e;
(5)
Adoption finalization papers showing the applicant’s name and place of birth in one of the 50 states, the
District of
Co
lumbia, Puerto Rico (on or after January 13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917
,
Am
erican Samoa, or the Northern Mariana Islands (on or after November 4, 1986, Northern Marian Islands local tim
e)
(unless the applicant was born to foreign diplomats residing in such a jurisdiction), or, when the adoption is not finalized
and the state or other U.S. jurisdiction listed above will not release a birth certificate prior to final adoption, a statement
from
a state or jurisdiction approved adoption agency showing the applicant’s name and place of birth in one of such
jurisdictions, and stating that the source of the information is an original bi
rth certificate;
(6)
Any other document that establishes a U.S. place of birth or otherwise indicates U.S. nationality (e.g., a contemporaneous
hospital record of birth in that hospital in one of the 50 states, the District of Columbia, Puerto Rico (on or after Janua
ry
1
3, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917), American Samoa, or the Northern Mariana Island
s
(o
n or after November 4, 1986, Northern Mariana Islands local time) (unless the applicant was born to foreign diplomat
s
resid
ing in such a jurisdictio
n);
c. Collective Naturalization
If the applicant cannot present one of the documents listed in (a) or (b) above, the following will establish U.S. citizenship for
collectively naturalized individuals:
Puerto Rico:
Ev
idence of birth in Puerto Rico on or after April 11, 1899 and the applicant’s statement that he or she was resi
ding in the
U
.S., a U.S. possession or Puerto Rico on January 13, 1941; or
Evidence that the applicant was a Puerto Rican citizen and the applicant’s statement that he or she was residing in Puerto
Rico on March 1, 1917 and that he or she did not take an oath of allegiance to Spain.
U.S. Virgin Islands:
Evidence of birth in the U.S. Virgin Islands, and the applicant’s statement of residence in the U.S., a U.S. possession or the
U.S. Virgin Islands on February 25, 1927;
The applicant’s statement indicating resident in the U.S. Virgin Islands as a Danish citizen on January 17, 1917 and
residence in the U.S., a U.S. possession or the U.S. Virgin Islands on February 25, 1927, and that he or she did not make
a
d
eclaration to maintain Danish citizenship;
or
Ev
idence of birth in the U.S. Virgin Islands and the applicant’s statement indicating residence in the U.S., a
U.S.
pos
session or territory or the Canal Zone on June 28, 1932.
Northern Mariana Islands (NMI) (formerly part of the Trust Territory of the Pacific Islands (TTPI)):
Evidence of birth in the NMI, TTPI citizenship and residence in the NMI, the U.S., or a U.S. territory or possession on
November 3, 1986 (NMI local time) and the applicant’s statement that he or she did not owe allegiance to a foreign state
on
November 4, 1986 (NMI local tim
e);
Ev
idence of TTPI citizenship, continuous residence in the NMI since before November 3, 1981 (NMI local time), vot
er
r
egistration prior to January 1, 1975 and the applicant’s statement that he or she did not owe allegiance to a foreign state on
November 4, 1986 (NMI local time); or
Evidence of continuous domicile in the NMI since before January 1, 1974 and the applicant’s statement that he or she did
not owe allegiance to a foreign state on November 4 1986 (NMI local time). Note: If a person entered the NMI as
a
n
onimmigrant and lived in the NMI since January 1, 1974, this does not constitute continuous domicile and the individua
l
is not a
U.S. ci
tizen
d. Derivati
ve Citize
nship
If the applicant cannot present one of the documents listed in a or b above, the following may be used to make determination of
derivative U.S. citizenship:
Applicant born abroad to two U.S. citizen parents: Evidence of the U.S. citizenship of the parents and the relationship of the
applicant to the parents, and evidence that at least one parent resided in the U.S. or an outlying passion prior to the applicant
’s
bi
rth.
Applicant born abroad to a U.S. citizen parent and a U.S. non-citizen national parent: Evidence that one parent
is a U.S.
citizen
and that the other is a U.S. non-citizen national, evidence of the relationship of the applicant to the U.S. citizen pare
nt,
and evi
dence that the U.S. citizen parent resided in the U.S., a U.S. possession, American Samoa or Swain’s Island for a period
of at least one year prior to the applicant’s birth.
Applicant born out of wedlock abroad to a U.S. citizen mother: Evidence of the U.S. citizenship of the mother, evidence
of
the relations
hip to the applicant and, for births on or before December 24, 1952, evidence that the mother resided in the
U.S.
pri
or to the applicant’s birth or, for births after December 24, 1952, evidence that the mother had resided, prior to the child’s
birth, in the U.S. or a U.S. possession for a period of one year
.
Applicant born in the Canal Zone or the Republic of Pana
ma:
A
birth certificate showing birth in the Canal Zone on or after February 26, 1904 and before October 1, 1979 and evid
ence
that one
parent was a U.S. citizen at the time of the applicant’s birth; or
A birth certificate showing birth in the Republic of Panama on or after February 26, 1904 and before October 1, 1979 an
d
evi
dence that at least one parent was a U.S. citizen and employed by the U.S. government or the Panama Railroad
Company or its successor in title.
In all other situations in which an applicant claims to have a U.S. citizen parent and an alien parent, or claims to fall within one
of the above categories, but is unable to present the listed documentation:
If the applicant is in the U.S., the applicant should contact the local U.S. Citizenship and Immigration Service office fo
r
d
etermination of U.S. citizenship;
If the applicant is outside the U.S., the applicant should contact the State Department for a U.S. citizenship determination.
e.
Adoption of Foreign-Born Child by U.S. Citize
n
If the birth certificate shows a foreign place of birth and the applicant cannot be determined to be a naturalized citizen
under any of the above criteria, obtain other evidence of U.S. citizenship;
Because foreign-born adopted children do not automatically acquire U.S. citizenship by virtue of adoption by
U.S. citizens,
the applicant s
hould contact the local U.S. Citizenship and Immigration Service office for a determination
of U.S.
citizen
ship, if the applicant provides no evidence of U.S. citizenship.
f. U.S. Citizenship By Marriage
A woman acquired U.S. citizenship through marriage to a U.S. citizen before September 22, 1922. Provide evidence of U.S.
citizenship of
the husband, and evidence showing the marriage occurred before September 22, 1922.
Note: If the husband was an alien at the time of the marriage, and became naturalized before September 22, 1922, the wife also
acquired naturalized citizenship. If the marriage terminated, the wife maintained her U.S. citizenship if she was residing in th
e
U.S. at that time and c
ontinued to reside in the U.S.
g. A U.S. certificate of birth abroad*
h. A foreign passport with a U.S. Visa*
i. An I-94 form with a photograph
j. A U.S. citizenship and immigration services employment authorization document or refugee travel
document*
LIST B
Qualified Aliens, Nonimmigrant, and aliens paroled into U.S. for less than one year.
a.
“
Qualified Aliens”
Evidence of “Qualified Alien” status includes the following:
Alien Lawfully admitted for Permanent Residence
-
*Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”);
or
- U
nexpired Temporary I-551 stamp in foreign passport or on *I Form I-94.
Asylee
-
*Form I-94 annotated with stamp showing grant of asylum under section 208 of the INA;
- *Form I-688B (Employment Authorization Card) annotated “274a.12 (a) (5)”
;
-
*
Form I-766 (Employment Authorization Document) annotated “A5”;
- Gran
t letter from the Asylum Office of the U.S. Citizenship and immigration Serv
ice; or
- O
rder of an immigration judge granting asylum
.
Refug
e
e
- *Fo
rm I-94 annotated with stamp showing admission under § 207 of the INA;
- *Form I-688B (Employment Authorization Card) annotated “274a.12 (a) (3)”
; or
- *
Form I-766 (Employment Authorization Document) annotated “A5”;
Alien Paroled Into the U.S. for at Least One Year
- *Form I-94 with stamp showing admission for at least one year under section 212(d) (5) of the INA. (Applicant cannot
aggregate
periods of admission for less than one year to meet the one-year requirement.
Alien Whose Deportation or Removal was withheld
- *Form I-688B (Employment Authorization Card) annotated “274a.12 (a) (10)”;
-
*
Form I-766 (Employment Authorization Document) annotated “A10”;
or
- O
rder from an immigration judge showing deportation withheld under §243(h) of the INA as in effect prior to
A
pril 1, 1997, or removal withheld under §241 (b) (3) of the INA.
Alien Granted Conditional Entry
- *Fo
rm I-94 with stamp showing admission under §203 (a) (7) of the INA;
- *Form I-688B (Employment Authorization Card) annotated “274a.12 (a) (3)”
; or
- *
Form I-766 (Employment Authorization Document) annotated “A3”.
Cuban/Haitia
n Entrant
-
*Form I-551 (Alien Registration Receipt Card, commonly known as a “green Card”) with the code CU6, CU7,
or CH6.
- Unexpired temporary I-551 stamp in foreign passport or on *Form I-94 with the Code CU6 or CU7; or
-
*Form I-94 with stamp showing parole as “Cuba/Haitian Entrant” under Section 212 (d) (5) of the INA.
Alien who has been Declared a Battered Alien or Alien Subjected to Extreme Cruelty
- U.S. Citizen
ship and Immigration Service petition and supporting documentatio
n
b. Nonimmigrant
Evidence of “Nonimmigrant” status includes the following:
- *Form I-94 with stamp showing authorized admission as nonimmigrant
c.
Alien Paroled into U.S. for less than One year
- *Form I-94 with stamp showing admission for less than one year under section 212 (d) (5) of the INA
d. A foreign passport with a U.
S. visa
e. An I-94 form with a photograph.
f. A U.S. citizenship and immigration services employment authorization document or refugee travel
document.
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