ALABAMA PROOF OF CITIZENSHIP FORM PDF (Poc Form)

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ABEC Proof of Citizenship Form pg 1 of 2 PROOF OF CITIZENSHIP (P oC) FORM This form must be completed by applicants for licensure in order to comply with Ala. Code §31- 13- 7 (1975 as amended).  Applicant’s Name (print clearly) : ______________________________________________________________ TRACK I  Complete this section if you are a United States Citizen.  I am a United States Citizen. I am submitting a COPY of one (1) of the document s listed below to prove citizenship (check which one ) . o Alabama Driver’s License or Identification issued by the Department of Public Safety o Driver’s License from other s tate that required proof of l awful presence o Birth Certificate indicating U.S. birth o Valid U.S. Passport o Military Identification showing U.S. as place of birth o Naturalization documents o Certificate of Citizenship o Consular Report of Birth Abroad of U.S. Citizen o Bureau of Indian Affairs identification o American Indian Card issued by Homeland Security o Final Adoption Decree showing person’s name and place of U.S. birth o A valid Uniformed Services Privileges and Identification Card o Extract from a U.S. hospital record of birth created at the time of the pe rson’s birth indicating the place of birth in the United States o Certification of Birth issued by U.S. Department of State  I hereby declare that I am a citizen of the United States of America. I sign this declar ation under penalty of perjury. M aking a f alse or fictitious statement or representation in this declaration is perjury in the second degree, pursuant to Ala. Code §13A -10- 102. Signature : ____________________________________________________ Date: _____________________ ABEC Proof of Citizenship Form pg 2 of 2 TRACK II  Complete this section if you are not a United States Citizen.  I am not a United States Citizen. I am submitting a COPY of one (1) of the documents listed below to prove legal presence in the United States. (check which one) . o I-327 Re -entry Permit o I-551 Permanent Resident Card o I-571 Refugee Travel Document o I-766 Employment Authorization Card o I-94 Arrival/Departure Record o Unexpired Foreign Passport o Temporary I -551 Stamp (on P assport or I -94) o I-20 Certificate of Eligibility for non -immigrant (F -1) student status o DS 2019 Cert ificate of Eligibility for Exchange Visitor (J -1) status o Machine- readable immigrant Visa (with temporary I -551 language) o Other (explain) : __________________________________________________________________________________________  I hereby declare that I am an alien lawfully present in the United States of America. I sign this declaration under penalty of perjury. M aking a false or fictitious statement or representation in this declaration is perjury in the second degree, pursuant to Ala. Code §13A -10- 102. Signature : ____________________________________________________ Date: _____________________ SUBMIT THIS FORM AND THE REQUIRED DOCUMENTATION TO: Alabama Board of Examiners in Counseling 2777 Zelda Rd. Montgomery, AL 36106 DO NOT SEND ORIGINALS OR FAXES OF CITIZENSHIP/LEGAL PRESENCE DOCUMENTS.