Fillable Printable Georgia Personal Identification for Registration
Fillable Printable Georgia Personal Identification for Registration
Georgia Personal Identification for Registration
STATE OF GEORGIA )
) AFFIDAVIT RE: PERSONAL IDENTIFICATION
COUNTY OF____________ ) FOR LICENSURE/REGISTRATION
PERSONALLY APPEARED before the undersigned officer, duly authorized to
administer oaths, came the undersigned, who after having been duly sworn, states under
oath the following:
1.
That my name is _____________________and that I am who I say I am;
2.
That my address is ____________________________________________;
3.
That I have presented sufficient identification to the notary that is true and
accurate;
4.
That I am legally in the United States of America;
5.
That I am applying to the Georgia Department of Human Services, Office of
Residential Child Care, to operate a business/activity to be located at the
following address: __________________________________________________
that subject to regulation by the Department of Human Services and that this
affidavit is a material part of the application; and
6.
That if the Department subsequently determines that the material information
contained in this affidavit is false, I will be in violation of licensing/registration
requirements, which may result in revocation of my license or registration or
denial of my application for licensure.
Sworn to and subscribed before me )
This _____ day of ______, ______ )
)
)_________________________
) Affiant
____________________________ )
NOTARY PUBLIC )
STATE OF GEORGIA )
My commission expires: _________.
List B
DOCUMENT THAT ESTABLISH IDENTITY
For individuals 18 years of older
•
Driver’s license or ID card issued by a state or outlying
possession of the United States provided it contains a
photograph or information such as name, date of birth, sex
height, eye color and address.
•
ID card issued by federal, state or local government
agencies or entities provided it contains a photograph or
information such as name, date of birth, sex, eye color,
and address (including U.S. citizen ID card [INS Form I-
197] and ID card for use of Resident Citizen in the U.S.
[INS Form I-179])
•
School identification card with a photograph
•
United States military card or draft record
•
Military dependent’s identification card
•
United States Coast Guard Merchant Marnier Card
•
Native American tribal document
•
Driver’s license issued by a Canadian government
authority
