ALABAMA BOARD OF ARCH ITE CT S
77 0 WASHINGTON AVENUE , SUITE 150
MONTGOMERY, AL ABAMA 36 1 3 0 -4450
www.boa.alabama.gov (334) 242-4179
CITI ZENS HIP AFFI DAVIT
APPLICANT’S FULL NAME:
NCARB FILE NUMBER: NCARB CERTIFICATE NUMBERLIDSSOLFDEOH:
CITY: STATE: ZIP:
ADDRESS CITY: STATE: ZIP:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
E-MA IL AD DRES S:
The Beason-Hammon Alabama Taxpayer and Citizen Protection Act of 2011 (Immigration Act) modified by Act 2012-491,
is codified as Title 31, Chapter 13 of the Code of Alabama 1975. The Act requires in Sections 7 and 30 that persons who
receive a professional license from a Board or Commission to demonstrate that they are either United States citizens or
legally present in the United States. Please attach supporting do cumentation th at will verify your citizenship status.
I am a United States citizen (documentation attached).
I am an alien who is legally present in the United States (documentation attach ed).
I am an alien outside the United States who is legally authorized to do business in the United States
I understand that this statement is required by law. I understand that making a false statement to the above questions
may subject me to disciplinary action under the laws of the State of Alabama.
Signature of Applicant Date