Fillable Printable Green Card Form - Miami University
Fillable Printable Green Card Form - Miami University
Green Card Form - Miami University
Green Card
Miami University - One Stop for Student Success Services - 301 S. Campus Ave. - Oxford, OH 45056
GREENC
The Department of Homeland Security could not confirm your statement that you are an eligible non-citizen. The
student must appear in person at One Stop for Student Success Services in the Campus Avenue Building to verify his
or her identity by presenting ONE of the following documents.
your Arrival Departure Record (form I-94), or
your Alien Registration Receipt Card (form I-151C), or
your Permanent Resident Card or Resident Alien Card (form I-551)
This form is for the collection of DHS or other U.S. citizenship/nationality documents from students unable to
present their documents in person.
I certify that I _____________________________ am the individual signing this statement, and I am providing a
(Print Student Name)
copy of my documents along with a copy of a valid government-issued photo identification card bearing my portrait.
I certify that the attached documents and government issued photo identification are the true, exact, and complete
copies of the originals issued to me.
List of document(s):
NAME OF VALID PHOTO ID
EXPIRATION DATE OF VALID PHOTO
ID
ISSUING AUTHORITY OF VALID
PHOTO ID
NAME OF CITIZENSHIP AND/OR IMMIGRATION
DOCUMENT(S)
EXPIRATION DATE (IF ANY) OF CITIZENSHIP AND/OR
IMMIGRATION DOCUMENT(S)
Page 1 of 2
SECTION I – To be completed by the student
SECTION II – Only complete if you are unable to present one of the above documents in person.
Section II must be completed by student and notary public on Page 2.
Green Card
Miami University - One Stop for Student Success Services - 301 S. Campus Ave. - Oxford, OH 45056
GREENC
This Notary’s Certificate of Acknowledgement must be completed by a notary and submitted with the information
on Page 1.
State of _____________________________ City/County of ____________________________________
On_____________________, before me, __________________________________________,
(DATE) (NOTARY’S NAME)
personally appeared, ____________________________________________, and provided to me
(PRINTED NAME OF STUDENT)
on basis of satisfactory evidence of identification _______________________________________
(TYPE OF GOVERNMENT-ISSUED PHOTO ID PROVIDED)
to be the above-named person who signed the foregoing instrument.
WITNESS my hand and official seal
(seal) ________________________________________
(NOTARY SIGNATURE)
My commission expires on _________________________
I understand that providing false or misleading information or documents is punishable by fine or imprisonment and
may make me liable for repayment of any funds received on the basis of the information and documents I have
provided.
_________________________________ ___________________ ________
Student’s Signature (Sign in the presence of a notary public) Student’s ID Number Date
Page 2 of 2
Student’s Signature
