Doug Ducey Joey Ridenour
Governor Executive Director
Arizona State Board of Nursing
1740 W Adams Street, Suite 2000
Phoenix. AZ 85007
Phone (602) 771-7800
Website: www.azbn.gov
AFFIDAVIT RE: LAWFUL PRESENCE DOCUMENTATION/SOCIAL SECURITY NUMBER FOR
FOREIGN NATIONAL APPLICANTS LIVING ABROAD
1. A.R.S. § 1-501 requires that:
Each licensing board or agency that issues professional licenses or certificates shall require documentation of citizenship or
nationality for licensure. If the documentation does not demonstrate that the applicant is a United States citizen, national, or
evidence of lawful presence in the United States/territories, the applicant will not be eligible for licensure in Arizona.
(Exception: International Nursing Recruits residing abroad).
2. A.R
.S. § 25-320(K) requires that:
Each licensing board or agency that issues professional, recreational or occupational licenses or certificates shall record on the
application the social security number of the applicant and shall enter this information in its data base in order to aid the
department of economic security in locating parents or their assets or to enforce child support orders.
3. I certify that I do not have a social security number or documentation to demonstrate that I am either a United States citizen, or
evidence of lawful presence to be a qualified alien in the United States/territories because
4. I understand that in the event I obtain evidence of lawful presence to be in the United States, I have the obligation to provide the
Board with a copy of my documentation within 20 days. My failure to do so may result in disciplinary action against my
license/certificate.
5. I understand that in the event I obtain a social security number, I have the obligation to provide the Board with a copy of my
social security card within 20 days. My failure to do so may result in disciplinary action against my license/certificate.
6. I understand that I must provide the Board, in writing with the name and address of my initial Arizona nursing employer, within
20 days of commencing employment.
7. I am currently living in ____________________________________awaiting authorization to relocate to the United States.
(Country)
When I have met the requirements for RN/LPN licensure, with the exception of presenting my social security number &
documentation of lawful presence in the United States, I authorize the Arizona State Board of Nursing to issue my license to me at
the following address, which is where I currently reside:
Name
Street
City:
State (Country)
On
ce my license has been issued, I authorize the Arizona State Board of Nursing to place the license on inactive status until such
time that I present to the Arizona State Board of Nursing; the documentation necessary to demonstrate lawful presence in the United
States.
(Signature of Applicant)
Returned signed document to: Arizona State Board of Nursing
