Green Card Form - Miami University Page 2
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1
2Green Card
This Notary’s Certificate of !cknowledgement must be completed by a notary and submitted with the information
on Page 1.
State of _____________________________ City/County of ____________________________________
On_____________________, before me, __________________________________________,
(D
)
(N
’
)
ATE
OTARY
S NAME
personally appeared, ____________________________________________, and provided to me
(P
)
RINTED NAME OF STUDENT
on basis of satisfactory evidence of identification _______________________________________
(T
-
ID
)
YPE OF GOVERNMENT
ISSUED PHOTO
PROVIDED
to be the above-named person who signed the foregoing instrument.
WITNESS my hand and official seal
(seal)
________________________________________
(N
)
OTARY SIGNATURE
My commission expires on _________________________
Student’s Signature
I understand that providing false or misleading information or documents is punishable by fine or imprisonment and
may make me liable for repayment of any funds received on the basis of the information and documents I have
provided.
_________________________________
___________________
________
Student’s Signature (Sign in the presence of a notary public)
Student’s ID Number
Date
FOR OFFICE USE ONLY:
Name of authorized individual who received the document:
_____________________
Page 2 of 2
Miami University - One Stop for Student Success Services - 301 S. Campus Ave. - Oxford, OH 45056
513-529-0001 - Email: OneStop@MiamiOH.edu - Fax: 513-529-8713 - Web: MiamiOH.edu/OneStop
GREENC
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