Affidavit Of Eligibility With Attachment A (Secure And Verifiable Documents)

AFFIDAVIT OF ELIGIBILITY Section A: LAWFUL PRESENCE in the United States. I, (please print your full name) ___________________________________________, swear or affirm under penalty of perjury under the laws of the State of Colorado that: (Check 1, 2 or 3 below) 1. ___ I am a U.S. citizen. 2. ___ I am not a U.S. citizen but am lawfully present in the U.S. as evidenced by one of the following (check a, b or c): a. ___ I am a qualified alien as defined in 8 U.S.C., Sec. 1641. b. ___ I am a non-immigrant under the "Immigration and Nationality Act", Federal Public Law 82-414 as amended. c. ___ I am an alien who is paroled into the U.S. under 8 U.S.C., Sec. 1182 (d) (5). 3. ___ I am a foreign national not physically present in the U.S, under 8 U.S.C., Sec. 1621 (c) (2) (c) or employed in the U.S. pursuant to 8 U.S.C.1621 (c) (2) (a). Complete documentation must be provided upon request. Section B: Secure and Verifiable Document. This section to be completed ONLY IF applying for an investment adviser representative license. 1. Please refer to Attachment A (on the reverse of this form) for a list of acceptable secure and verifiable documents and enter the documentation you have ___________________________. 2. Please enter the name of the state or the federal agency name where this was issued __________________________________. 3. What is the document number ____________________? 4. What is the expiration date _______________________? Section C: Attestation. · I understand that this sworn statement is required by law because I have applied for or hold a professional or commercial license regulated by 8 U.S.C., Sec. 1621. I understand that state law requires me to provide proof that I am lawfully present in the United States when asked, as well as submission of a secure and verifiable document. I may also be required to provide proof of lawful presence. I understand that in accordance with Sections 18-8-503 and 18-8-501 (2) (a) (l), C.R.S., false statements made herein are punishable by law. I state under penalty of perjury in the second degree, as defined in 18-8-503, C.R.S. that the above statements are true and correct. I am the person identified above and that the information contained herein is true and correct to the best of my knowledge. I understand that under Colorado law, providing false information is grounds for denial, suspension or revocation of a license, certificate, registration or permit. I understand that the above information must be disclosed to the Department of Regulatory Agencies upon request and is subject to verification. _______________________ Date · · · ________________________________________________ Signature American LegalNet, Inc. www.FormsWorkFlow.com Attachment A Secure and Verifiable Documents · Any Colorado Driver License, Colorado Driver Permit or Colorado Identification Card, expired less than one year. (Temporary paper license with invalid Colorado Driver License, Colorado Driver Permit or Colorado Identification Card, expired less than one year is considered acceptable.) Out-of-state issued photo Driver's License or photo identification card, photo driver's permit expired less than one year. Valid foreign passport with 1-94 or valid Processed For 1551 stamps. Valid 1-94 issued by Canadian government with L1 or R1 status and a valid Canadian driver's license or valid Canadian identification card. Valid 1551 Resident Alien/Permanent Resident card. NO border crosser or USA B1/B2 Visa/BCC cards. Valid 1688 Temporary Resident Card, 1688B and 1766 Employment Authorization Card. Valid U.S. Military ID (active duty, dependent, retired, reserve and National Guard). Tribal Identification Card with intact photo (US or Canadian). Certificate of Naturalization with intact photo. Certificate of (US) Citizenship with intact photo. www.FormsWorkflow.com