Form 1IS "Citizenship/Immigration Status" - New York

What Is Form 1IS?

This is a legal form that was released by the New York State Education Department - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2016;
  • The latest edition provided by the New York State Education Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 1IS by clicking the link below or browse more documents and templates provided by the New York State Education Department.

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Download Form 1IS "Citizenship/Immigration Status" - New York

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Form 1IS
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
www.op.nysed.gov
Citizenship/Immigration Status
Applicant Instructions: Federal law and the Regulations of the Commissioner of Education (8 NYCRR §59.4) limit the issuance of
professional licenses, registrations and limited permits to United States citizens or qualified aliens. To comply with Federal law and
Commissioner’s regulation, you must complete this section of this form and check the appropriate box below which indicates your
citizenship/immigration status.
1
Profession: ________________________________________________________________________________________________
3
2
Social Security Number
Birth Date Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
4
Print Name
Last
First
Middle
5
Mailing Address
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
6
Citizenship/Immigration Status
Check the appropriate box indicating your citizenship/immigration status.
I am:
 A. A United States citizen or National.
 B. An alien lawfully admitted for permanent residence in the United States.
 C. An alien granted asylum under Section 208 of the Immigration and Nationality Act.
 D. A refugee granted asylum under Section 207 of the Immigration and Nationality Act.
 E. An alien paroled into the United States under Section 212 (d)(5) of the Immigration and Nationality Act for a period of at least 1 year.
 F. An alien whose deportation is being withheld under Section 241 (b)(3) of the Immigration and Nationality Act.
 G. An alien granted conditional entry pursuant to Section 203 (a)(7) of the Immigration and Nationality Act as in effect prior to April 1980.
 H. Non Immigrant (Temporarily in U.S.) Please list Visa type or immigration status or attach a copy of your passport if you are not required to have
a Visa to enter the United States: _______________________________________
 I.
I am an alien not unlawfully present in the United States pursuant to the Deferred Action for Childhood Arrivals (DACA) relief or similar relief
from deportation. Please specify: _______________________________________
 J. I do not reside in the United States.
If you checked any of the boxes from B-I, enter your alien registration number or control number issued by the United States Citizenship and
Immigration Services (USCIS):
USCIS number: ___________________________________________
QUESTIONS ABOUT YOUR IMMIGRATION STATUS AND WHETHER OR NOT IT IS A QUALIFYING STATUS UNDER FEDERAL LAW SHOULD
BE DIRECTED TO THE U.S. CITIZENSHIP AND IMMIGRATION SERVICES (USCIS) BY CALLING 1-800-375-5283, OR VISIT THEIR WEB SITE
AT WWW.USCIS.GOV.
7
Attestation
I declare and affirm under penalty of perjury that the above information is true, and correct. I understand that any false or misleading
information in, or in connection with, my application may be the cause for denial or loss of licensure and may result in criminal
prosecution.
Signature: ______________________________________________________________ Date: _______________________________
Return Directly to:
New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
_____________________________________________ Unit, 89 Washington Avenue, Albany, NY 12234-1000
(Insert name of profession)
Form 1IS, Rev. 6/16
1.
2.
3.
4.
5.
6.
Form 1IS
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
www.op.nysed.gov
Citizenship/Immigration Status
Applicant Instructions: Federal law and the Regulations of the Commissioner of Education (8 NYCRR §59.4) limit the issuance of
professional licenses, registrations and limited permits to United States citizens or qualified aliens. To comply with Federal law and
Commissioner’s regulation, you must complete this section of this form and check the appropriate box below which indicates your
citizenship/immigration status.
1
Profession: ________________________________________________________________________________________________
3
2
Social Security Number
Birth Date Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
4
Print Name
Last
First
Middle
5
Mailing Address
(You must notify the Department promptly of any address or name changes.)
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
6
Citizenship/Immigration Status
Check the appropriate box indicating your citizenship/immigration status.
I am:
 A. A United States citizen or National.
 B. An alien lawfully admitted for permanent residence in the United States.
 C. An alien granted asylum under Section 208 of the Immigration and Nationality Act.
 D. A refugee granted asylum under Section 207 of the Immigration and Nationality Act.
 E. An alien paroled into the United States under Section 212 (d)(5) of the Immigration and Nationality Act for a period of at least 1 year.
 F. An alien whose deportation is being withheld under Section 241 (b)(3) of the Immigration and Nationality Act.
 G. An alien granted conditional entry pursuant to Section 203 (a)(7) of the Immigration and Nationality Act as in effect prior to April 1980.
 H. Non Immigrant (Temporarily in U.S.) Please list Visa type or immigration status or attach a copy of your passport if you are not required to have
a Visa to enter the United States: _______________________________________
 I.
I am an alien not unlawfully present in the United States pursuant to the Deferred Action for Childhood Arrivals (DACA) relief or similar relief
from deportation. Please specify: _______________________________________
 J. I do not reside in the United States.
If you checked any of the boxes from B-I, enter your alien registration number or control number issued by the United States Citizenship and
Immigration Services (USCIS):
USCIS number: ___________________________________________
QUESTIONS ABOUT YOUR IMMIGRATION STATUS AND WHETHER OR NOT IT IS A QUALIFYING STATUS UNDER FEDERAL LAW SHOULD
BE DIRECTED TO THE U.S. CITIZENSHIP AND IMMIGRATION SERVICES (USCIS) BY CALLING 1-800-375-5283, OR VISIT THEIR WEB SITE
AT WWW.USCIS.GOV.
7
Attestation
I declare and affirm under penalty of perjury that the above information is true, and correct. I understand that any false or misleading
information in, or in connection with, my application may be the cause for denial or loss of licensure and may result in criminal
prosecution.
Signature: ______________________________________________________________ Date: _______________________________
Return Directly to:
New York State Education Department, Office of the Professions, Division of Professional Licensing Services,
_____________________________________________ Unit, 89 Washington Avenue, Albany, NY 12234-1000
(Insert name of profession)
Form 1IS, Rev. 6/16