Persons with disabilities may request reasonable accommodations by contacting the Americans with Disabilities Act Coordinator at (602) 542-
3578. Requests should be made as early as possible to allow time to arrange the accommodation. 2018.10– RLT
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Director
DOUGLAS A. DUCEY
Governor
ARIZONA DEPARTMENT OF AGRICULTURE
STATEMENT OF LAWFUL PRESENCE TO RECEIVE PUBLIC BENEFITS
LICENSES/ CERTIFICATIONS
Arizona Revised Statutes § 41-1080 requires that an individual applying for a license issued by the Department—(i) for
the purpose of operating a business in Arizona or (ii) to someone who provides a service to any person where the license
is necessary in performing that service—must submit certain documentation that satisfactorily demonstrates that the
applicant is lawfully present in the United States. If the documentation does not contain a photograph of the applicant,
the applicant must also present a government issued document that contains a photograph.
Directions: All individual applicants for a license or certification covered by these laws must complete this form
and provide evidence by submitting a copy (front and back, if any) of one or more documents from the lists below
declaring your citizenship or lawful alien status with your application. If your documentation of lawful presence
does not have a photograph, you must also provide a government issued id with a photograph. If the Department
has evidence you have previously submitted proof of United States citizenship or a non-expiring work
authorization issued by the federal government, you do not have to do so again. Please DO NOT provide a copy
of your Social Security Card.
APPLICANT INFORMATION
APPLICANT’S LEGAL NAME (Print or type) ________________________________________________________
TYPE OF LICENSE/CERTIFICATION APPLICATION (check one)
NEW RENEWAL
EVIDENCE OF CITIZENSHIP, NATIONAL OR ALIEN STATUS
Evidence of Citizenship – please check the box corresponding to the document you are
providing. The following documents need only be supplied once as long you remain certified.
☐ 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 diplomats residing in such a jurisdiction);
☐ Form N-550 or N-570, United States Certificate of Naturalization
☐ Form DD-214 (Report of Separation Military Discharge Document) showing US Place of Birth
☐ United States Passport; or A foreign passport with a United States visa.
☐ Report of birth abroad of a U.S. citizen (FS-240) (issued by the Department of State to U.S. citizens);
Certificate of Birth (FS-545) (issued by a Foreign Service post) or Certification of Report of Birth (DS-
1350); Statement provided by a U.S. consular official certifying that the individual is a U.S. citizen
☐ Form N-561, Certificate of Citizenship
☐ Form I-197, United States Citizen Identification Card
☐ Form I-873 (or prior versions), Northern Marianas Card
☐ Statement 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 an
FS-240, FS-545, or DS-1350)
☐ Form I-872 (or prior versions), American Indian Card with a classification code "KIC"; A tribal
certificate of Indian blood; or A tribal or bureau of Indian affairs affidavit of birth.
