This form must be completed entirely. Any applicable attachments must be included as indicated below.
Citizenship / Alien Status Affirmation
*NOTARY NOT NEEDED*
Instructions: All natural persons fourteen (14) years of age and older, present in the United
, States, applying for a license with the Oklahoma State Board of Pharmacy are required by 56
O.S. Section 71 to provide the Board with verification of lawful presence in the US by executing
the following Affirmation (as authorized by 56 OS Section 71, Subsection G).
I, _______________________________________make affirmation, under penalty of perjury, as follows:
Print your name clearly here
(PLEASE SELECT ONE OF THE FOLLOWING, then sign and date)
_____ I am a United States Citizen
_____ I am a Qualified Alien* under Federal Immigration and Naturalization Act; and,
I am lawfully present in the United States. Complete the following if you are an alien:
Alien Registration Number: _________________________________________________
County of Origin: ___________________________________________________________
Date of Birth: ________________________________________________________________
U.S. Social Security Number: ________________________________________________
*When Qualified Alien is selected, the applicant / registrant must attach a legible copy of
the front and back of the United States federal work authorization document.
Signature:_________________________________________________
Date signed: __________________________
OKLAHOMA STATE BOARD OF PHARMACY * 2920 N LINCOLN BLVD STE A * OKLAHOMA CITY, OK 73105-4212
Citizenship / Alien Status Affirmation
*NOTARY NOT NEEDED*
Instructions: All natural persons fourteen (14) years of age and older, present in the United
, States, applying for a license with the Oklahoma State Board of Pharmacy are required by 56
O.S. Section 71 to provide the Board with verification of lawful presence in the US by executing
the following Affirmation (as authorized by 56 OS Section 71, Subsection G).
I, _______________________________________make affirmation, under penalty of perjury, as follows:
Print your name clearly here
(PLEASE SELECT ONE OF THE FOLLOWING, then sign and date)
_____ I am a United States Citizen
_____ I am a Qualified Alien* under Federal Immigration and Naturalization Act; and,
I am lawfully present in the United States. Complete the following if you are an alien:
Alien Registration Number: _________________________________________________
County of Origin: ___________________________________________________________
Date of Birth: ________________________________________________________________
U.S. Social Security Number: ________________________________________________
*When Qualified Alien is selected, the applicant / registrant must attach a legible copy of
the front and back of the United States federal work authorization document.
Signature:_________________________________________________
Date signed: __________________________
OKLAHOMA STATE BOARD OF PHARMACY * 2920 N LINCOLN BLVD STE A * OKLAHOMA CITY, OK 73105-4212
