Sed 9-L - Application For State Electrical License Renewal Page 2
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4United States Citizenship Attestation Form
For the purpose of complying with Neb. Rev. Stat. §§ 4-108 through 4-114, I attest as
follows:
■
I am a citizen of the United States.
— OR —
■
I am a qualified alien under the federal Immigration and Nationality Act, my immigration
status and alien number are as follows: __________________________________,
and I agree to provide a copy of my USCIS documentation upon request.
I hereby attest that my response and the information provided on this form and
any related application for public benefits are true, complete, and accurate and I
understand that this information may be used to verify my lawful presence in
the United States.
PRINT NAME
(first, middle, last)
SIGNATURE
DATE
ELECTRICAL LICENSE # ___________________________________________
7/2009
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