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Citizenship Information Form


Citizenship Information Form

Version 2.0

Section 1
Last Name:
First Name:
Middle Initial:
Social Security Number:


(First 8 digits on BC Eagle-One Card)
Daytime Telephone Number:
( )
Section 2 (If Yes, proceed to Section 4)
I am a U.S. Citizen Yes No
Section 3 (U.S. Permanent Residents only)
I am a U.S. Permanent Resident YesNo
(please attach a copy of your Alien Registration Card ("green card") and fill out Section 3 below)
Country of Citizenship:
Dates on "Green Card" (use mm/dd/yyyy format):from to
Section 4 (optional)
Voluntary Self-Identification:
Section 5
I verify that the above information is correct:

Signature: ________________________________ Date: __________