OSDH Form 301 "Affidavit of Lawful Presence" - Oklahoma

What Is OSDH Form 301?

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

Form Details:

  • Released on October 1, 2021;
  • The latest edition provided by the Oklahoma State Department of Health;
  • 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 fillable version of OSDH Form 301 by clicking the link below or browse more documents and templates provided by the Oklahoma State Department of Health.

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Download OSDH Form 301 "Affidavit of Lawful Presence" - Oklahoma

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AFFIDAVIT OF LAWFUL PRESENCE
BY PERSON MAKING APPLICATION FOR A LICENSE, PERMIT OR CERTIFICATE
I, the undersigned applicant, being of lawful age, state that one of the following statements is true and correct:
(Check only ONE of the following statements that apply)
I am a United States citizen.
I am an approved alien under the federal Immigration and Nationality Act and am approved to be
present in the United States. I understand this approval may or may not include approval for
employment. The issuance of a license, permit or certificate by the Oklahoma State Department of
Health is not authorization for employment in the United States.
Admission/Registration #
Authorizing Document:
(Attach a copy of the authorizing document.)
I state under penalty of perjury under the laws of Oklahoma that the foregoing is true and correct and that I have
read and understand this form and completed it in my own hand.
Print Name:
Date:
City:
State:
Signature: _____________________________________________________________________
For RENEWAL license, permit or certificate, please write the number:
(Current license, permit or certificate number)
INSTRUCTIONS FOR USE OF THIS AFFIDAVIT OF LAWFUL PRESENCE FORM:
The person signing this form must read these instructions carefully.
1. If the person signing this form is receiving services and not making an application for a license, permit or certificate, this form
should not be used but rather, either the form titled, "Affidavit of Lawful Presence by Parent or Guardian of Person Receiving
Services" or the form titled "Affidavit of Lawful Presence by Person Receiving Services" should be used.
2. If the person signing this form is a citizen of the United States then that person should check the box to the left of the statement,
"I am a citizen of the United States." If the person signing this form is not a citizen of the United States but is an approved alien under
the federal Immigration and Nationality Act and is lawfully present in the United States then that person should check the box to the
left of the statement, "I am an approved alien under the federal Immigration and Nationality Act and am approved to be present in the
United States."
3. If an approved alien, write the identification number in the “Admission/Registration #” field and write the name of the authorizing
document in the “Authorizing Document” field. (Examples of authorizing documents are: INS Form I-551 or INS Form I-94)
4. The person signing this form should write today’s date in the space provided; write the city and state where they are actually located
when they sign this form print and sign their name in the space provided; and if only if applying for a renewal write the current
license, permit or certificate number in the space provided.
5. Within this form, the term "penalty of perjury" means the willful assertion of the fact of either United States citizenship or lawful
presence in the United States as a qualified alien, and made upon one's oath or affirmation and knowing such assertion to be false.
Making such a willful assertion on this form knowing it to be false is a crime in Oklahoma and may be punishable by a term of
incarceration of not more than five (5) years in prison. Additionally, one who procures another to commit perjury is guilty of the crime
of subornation of perjury and may be punished in the same manner, as he would be if personally guilty of the perjury so procured.
Oklahoma State Department of Health
ODH Form 301
10/2021
Protective Health Services
AFFIDAVIT OF LAWFUL PRESENCE
BY PERSON MAKING APPLICATION FOR A LICENSE, PERMIT OR CERTIFICATE
I, the undersigned applicant, being of lawful age, state that one of the following statements is true and correct:
(Check only ONE of the following statements that apply)
I am a United States citizen.
I am an approved alien under the federal Immigration and Nationality Act and am approved to be
present in the United States. I understand this approval may or may not include approval for
employment. The issuance of a license, permit or certificate by the Oklahoma State Department of
Health is not authorization for employment in the United States.
Admission/Registration #
Authorizing Document:
(Attach a copy of the authorizing document.)
I state under penalty of perjury under the laws of Oklahoma that the foregoing is true and correct and that I have
read and understand this form and completed it in my own hand.
Print Name:
Date:
City:
State:
Signature: _____________________________________________________________________
For RENEWAL license, permit or certificate, please write the number:
(Current license, permit or certificate number)
INSTRUCTIONS FOR USE OF THIS AFFIDAVIT OF LAWFUL PRESENCE FORM:
The person signing this form must read these instructions carefully.
1. If the person signing this form is receiving services and not making an application for a license, permit or certificate, this form
should not be used but rather, either the form titled, "Affidavit of Lawful Presence by Parent or Guardian of Person Receiving
Services" or the form titled "Affidavit of Lawful Presence by Person Receiving Services" should be used.
2. If the person signing this form is a citizen of the United States then that person should check the box to the left of the statement,
"I am a citizen of the United States." If the person signing this form is not a citizen of the United States but is an approved alien under
the federal Immigration and Nationality Act and is lawfully present in the United States then that person should check the box to the
left of the statement, "I am an approved alien under the federal Immigration and Nationality Act and am approved to be present in the
United States."
3. If an approved alien, write the identification number in the “Admission/Registration #” field and write the name of the authorizing
document in the “Authorizing Document” field. (Examples of authorizing documents are: INS Form I-551 or INS Form I-94)
4. The person signing this form should write today’s date in the space provided; write the city and state where they are actually located
when they sign this form print and sign their name in the space provided; and if only if applying for a renewal write the current
license, permit or certificate number in the space provided.
5. Within this form, the term "penalty of perjury" means the willful assertion of the fact of either United States citizenship or lawful
presence in the United States as a qualified alien, and made upon one's oath or affirmation and knowing such assertion to be false.
Making such a willful assertion on this form knowing it to be false is a crime in Oklahoma and may be punishable by a term of
incarceration of not more than five (5) years in prison. Additionally, one who procures another to commit perjury is guilty of the crime
of subornation of perjury and may be punished in the same manner, as he would be if personally guilty of the perjury so procured.
Oklahoma State Department of Health
ODH Form 301
10/2021
Protective Health Services