Cna Renewal Application Form (Page 8 of 14) in pdf

*10. CITIZENSHIP OR NATIONAL STATUS DECLARATION

Yes

Are you a citizen of the United States?

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. To see a list of other accepted documents, visit

and click on ‘Statement of Citizenship and Alien Status’.

If you have already submitted a proof of citizenship/nationality document after 1/1/08 you will not need to submit the document

again.



Type of document you are submitting (i.e. passport, birth certificate)

Already Submitted

Expiration Date, if any (mm/dd/yyyy)

If you are a citizen or national of the United States, go directly to Question 12. If you are not a citizen or national of the United States, complete

question 11.

*11. 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

and clicking on Statement of Citizenship and Alien Status.

“Qualified Alien” Status

A. An alien lawfully admitted for permanent residence under the Immigration and Nationality Act (INA).

B. An alien who is granted asylum under Section 208 of the INA.

C. A refugee admitted to the United States under Section 207 of the INA.

D. An alien paroled into the United States for at least one year under Section 212(d)(5) of the INA.

E. An alien whose deportation is being withheld under section 243(h) of the INA.

F. An alien granted conditional entry under Section 203(a) (7) of the INA as in effect prior to April1,1980.

G. An alien who is a Cuban and Haitian entrant (as defined in section 501(e) of the Refugee Education Assistance Act of 1980).

H. 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.

Nonimmigrant Status (8 U.S.C § 1621(a) (2))

I. 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 8 U.S.C § 1101(a) (15).

Alien paroled into the United States for less than one year (8 U.S.C § 1621(a) (3))

J. An alien paroled into the United States for less than one year under Section 212(d) (5) of the INA.

Other Person (8 U.S.C § 1621 (c) (2) (A) and (C))

K. A nonimmigrant whose visa for entry is related to employment in the United States

L. 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.];

M. A foreign national not physically present in the United States.

Otherwise Lawfully Present (A.R.S. § 1-501)

N. 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.

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)

CNRD

Cna Renewal Application Form Page 8

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