Cna Renewal Application Form (Page 2 of 14) in pdf

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 issued 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 diplomats

residing in such a jurisdiction); *

(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), copies of

which 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 through

administrative naturalization after December 1990 to individuals who are individually naturalized; the N-570 is a

replacement certificate issued when the N-550 has been lost or mutilated or the individual’s name has changed);

(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) 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 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 border).

(13) A tribal certificate of Indian blood.*

(14) A tribal or bureau of Indian affairs affidavit of birth*

NOTE: SOCIAL SECURITY CARDS ARE NOT ACCEPTABLE DOCUMENTATION.

b. Secondary Evidence

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),

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) within three 3 months after birth showing that the birth occurred in such jurisdiction and the date of

birth or the individual’s age at the time the record was made;

(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 age;

(5) Adoption finalization papers showing the applicant’s name and place of 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 Marian Islands local time)

(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 birth 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 January

13, 1941), Guam, the U.S. Virgin Islands (on or after January 17, 1917), American Samoa, or the Northern Mariana Islands

Cna Renewal Application Form Page 2

Related Articles

Related forms

Related Categories