La Citoyennete? et de l?Immigration Baronnie de Saint Aldwin
Citizenship and Immigration Barony of Saint Aldwin
Demande de Citoyennete?
Application for Citizenship
1. I want service in (please check one): ___ French __X__ Common
2. Name exactly as shown on birth certificate or previous certificate:
???.Last Name (Surname): Bertand
???.Given Name(s): Annie-Love Harper
3. Previous Name(s) including birth name, maiden, previous married name(s), aliases or nicknames. These names will not appear on your citizenship certificate:
???.Last Name (Surname/Family name): Harper
???.Given Name(s): Annie-Love
4. Date of birth (CYE): __07-23-1982__
5. Birth Details:
???.Place, country and world of birth: Plattsburgh AFB Military Hospital, Plattsburgh, New York, United States of America, Earth (altid 03048)
6. Personal Information:
???.Gender: _____ Male __X__ Female
???.Height: __5__ feet __5__inches
???. Weight: __123__lbs
???. Hair Color: __Blonde__
???. Eye Color: __Grey__
???. Marital Status: _____Single __X__ Married _____ Common-law _____ Widowed _____ Divorced _____Separated
6. Current spouse, if applicable:
???. Date of marriage (CYE): __12-07-2012__
???. Last Name (Surname): Bertand
???. Given Name(s): Luca Johannes
???. Spouse Country of birth: __Icecrest__
???. Spouse Date of Birth: _11-01-1980_
???. Is spouse a citizen of Saint Aldwin?: __X__ Yes _____ No
???. By _____ Birth OR __X__ Naturalization
???. Number on spouse?s citizenship certificate (if applicable): _0008640285_
7. Other Nationalities:
Are you a citizen of one or more countries other than Saint Aldwin? If YES, list the country(ies), date, and how you obtained this citizenship: __X__ Yes _____ No
__United States of America (Earth alt 03048), 07-23-1982, birth__
8. Current Residence:
???. Address: __100 Mill Road, Teobern, SA__
???. Communique: __1-983-729-75__
9. Other residence(s), if applicable:
???. Address: 38901 Lakewood Drive, New Haven, RhyDin
???. Communique: __same (mobile)__
10. Applicant?s Parents (Answer for all natural and adoptive parents):
Father __X__ Natural _____ Adoptive
???. Name (Last name/Surname, given name): __Harper, William James__
???. Country and date of birth (CYE): __United States of America, 02-28-1950__
???. Country and date of marriage (CYE):__United States of America, 06-05-1979__
???. Was he a citizen of the Barony of Saint Aldwin? _____ Yes __X__ No
???. Was he employed in Saint Aldwin by a foreign government or international agency? _____ Yes __X__ No
???. If Yes, provide details: ___________________
???. At the time of your birth, was he employed outside of Saint Aldwin by the Barony of Saint Aldwin or a public service agency of the Barony of Saint Aldwin other than as a locally engaged person?
_____ Yes __X__ No
???. If Yes, provide details: ___________________
???. If father was born in Saint Aldwin, was one of HIS parents employed by a foreign government or international agency? _____ Yes __X__ No
???. If Yes, provide details: ___________________
Mother __X__ Natural _____ Adoptive
???. Married Name (Last name/Surname, given name): __Harper, Julia Elisabeth__
???. Maiden Name (Last name/Surname): __Peale__
???. Country and date of birth (CYE): __United States of America, 11-16-1958__
???. Country and date of marriage (CYE):__United States of America, 06-05-1979__
???. Was she a citizen of the Barony of Saint Aldwin? _____ Yes __X__ No
???. Was she employed in Saint Aldwin by a foreign government or international agency? _____ Yes __X__ No
???. If Yes, provide details: ___________________
???. At the time of your birth, was she employed outside of Saint Aldwin by the Barony of Saint Aldwin or a public service agency of the Barony of Saint Aldwin other than as a locally engaged person?
_____ Yes __X__ No
???. If Yes, provide details: ___________________
???. If mother was born in Saint Aldwin, was one of HER parents employed by a foreign government or international agency? _____ Yes __X__ No
???. If Yes, provide details: ___________________
11. Applicant?s Grandparents:
??.? If applicant?s FATHER was born outside of Saint Aldwin, was one of his parents a citizen of the Barony of Saint Aldwin at the time of his birth? _____Yes __X__ No
???. If Yes, provide details: (full name, country and date of birth): ___________________
??.? If applicant?s MOTHER was born outside of Saint Aldwin, was one of her parents a citizen of the Barony of Saint Aldwin at the time of her birth? _____Yes __X__ No
???. If Yes, provide details: (full name, country and date of birth): ___________________
12. Have you ever lived in Saint Aldwin? __X__ Yes _____ No
???. If Yes, have on what date did you enter Saint Aldwin to live?: __12-07-2012__
================================================== =========================
ATTESTATION:
I understand the content of this form. I declare that the information provided is true, correct and complete and that the photographs enclosed are a true likeness of me. I understand that if I make a false declaration or fail to disclose all information material to my application, my citizenship certificate could be taken away and that I could be charged under the Citizenship Act.
Signature of Applicant: __Annie-Love Harper Bertand__
Date: __01-28-2013__
???. Did you receive any assistance in completing this form? _____ Yes __X__ No
???. If Yes, provide full name and address of individual or organization who assisted: ____________
Signature of Assistant: ________________
Date: _________________
================================================== =========================
DOCUMENTATION CHECKLIST:
Send the following documents with your application. Check each box once you enclose the item.
Failure to provide a fully completed application form or the necessary documents will result in the return of your application. If you are sending more than one application (for example, family members), and one of the applications is incomplete, all applications will be returned to you.
If the application is for your first citizenship certificate, provide originals or clear and legible certified copies of your documents.
If the application is for a replacement certificate, provide clear and legible photocopies of your documents.
__X__ Application for a Citizenship Certificate, fully completed, signed and dated. See section ?Step 2. Complete the Application? in the instruction guide to know how to complete the form.
__X__ Two (2) pieces of personal identification, one of which MUST have your photo on it. If there is information on both sides of your personal identification documents, provide a photocopy of both sides.
__X__Two (2) citizenship photos. See ?Citizenship Photographs Specifications? in the instruction guide.
__X__ Fees. Enclose two (2) copies of the Receipt form showing the amount paid. See ?Step 3. Pay the Fees? in the instruction guide for the acceptable methods of payment.
__NA__ Original translation (if applicable) of any documents that are not in French or Common and an affidavit from the translator. See ?Step 1. Gather Documents? in the instruction guide.
INCLUDE THIS COMPLETED DOCUMENT CHECKLIST WITH YOUR APPLICATION PACKAGE.
================================================== ============================
Official use only
DCI no. _____________________
Case ID _____________________
Certificate No. ___________________
_____ Return original documents
_____ Approved
Signature: ____________________________
Date: __________________________
Notify: _________________________________
Citizenship and Immigration Barony of Saint Aldwin
Demande de Citoyennete?
Application for Citizenship
1. I want service in (please check one): ___ French __X__ Common
2. Name exactly as shown on birth certificate or previous certificate:
???.Last Name (Surname): Bertand
???.Given Name(s): Annie-Love Harper
3. Previous Name(s) including birth name, maiden, previous married name(s), aliases or nicknames. These names will not appear on your citizenship certificate:
???.Last Name (Surname/Family name): Harper
???.Given Name(s): Annie-Love
4. Date of birth (CYE): __07-23-1982__
5. Birth Details:
???.Place, country and world of birth: Plattsburgh AFB Military Hospital, Plattsburgh, New York, United States of America, Earth (altid 03048)
6. Personal Information:
???.Gender: _____ Male __X__ Female
???.Height: __5__ feet __5__inches
???. Weight: __123__lbs
???. Hair Color: __Blonde__
???. Eye Color: __Grey__
???. Marital Status: _____Single __X__ Married _____ Common-law _____ Widowed _____ Divorced _____Separated
6. Current spouse, if applicable:
???. Date of marriage (CYE): __12-07-2012__
???. Last Name (Surname): Bertand
???. Given Name(s): Luca Johannes
???. Spouse Country of birth: __Icecrest__
???. Spouse Date of Birth: _11-01-1980_
???. Is spouse a citizen of Saint Aldwin?: __X__ Yes _____ No
???. By _____ Birth OR __X__ Naturalization
???. Number on spouse?s citizenship certificate (if applicable): _0008640285_
7. Other Nationalities:
Are you a citizen of one or more countries other than Saint Aldwin? If YES, list the country(ies), date, and how you obtained this citizenship: __X__ Yes _____ No
__United States of America (Earth alt 03048), 07-23-1982, birth__
8. Current Residence:
???. Address: __100 Mill Road, Teobern, SA__
???. Communique: __1-983-729-75__
9. Other residence(s), if applicable:
???. Address: 38901 Lakewood Drive, New Haven, RhyDin
???. Communique: __same (mobile)__
10. Applicant?s Parents (Answer for all natural and adoptive parents):
Father __X__ Natural _____ Adoptive
???. Name (Last name/Surname, given name): __Harper, William James__
???. Country and date of birth (CYE): __United States of America, 02-28-1950__
???. Country and date of marriage (CYE):__United States of America, 06-05-1979__
???. Was he a citizen of the Barony of Saint Aldwin? _____ Yes __X__ No
???. Was he employed in Saint Aldwin by a foreign government or international agency? _____ Yes __X__ No
???. If Yes, provide details: ___________________
???. At the time of your birth, was he employed outside of Saint Aldwin by the Barony of Saint Aldwin or a public service agency of the Barony of Saint Aldwin other than as a locally engaged person?
_____ Yes __X__ No
???. If Yes, provide details: ___________________
???. If father was born in Saint Aldwin, was one of HIS parents employed by a foreign government or international agency? _____ Yes __X__ No
???. If Yes, provide details: ___________________
Mother __X__ Natural _____ Adoptive
???. Married Name (Last name/Surname, given name): __Harper, Julia Elisabeth__
???. Maiden Name (Last name/Surname): __Peale__
???. Country and date of birth (CYE): __United States of America, 11-16-1958__
???. Country and date of marriage (CYE):__United States of America, 06-05-1979__
???. Was she a citizen of the Barony of Saint Aldwin? _____ Yes __X__ No
???. Was she employed in Saint Aldwin by a foreign government or international agency? _____ Yes __X__ No
???. If Yes, provide details: ___________________
???. At the time of your birth, was she employed outside of Saint Aldwin by the Barony of Saint Aldwin or a public service agency of the Barony of Saint Aldwin other than as a locally engaged person?
_____ Yes __X__ No
???. If Yes, provide details: ___________________
???. If mother was born in Saint Aldwin, was one of HER parents employed by a foreign government or international agency? _____ Yes __X__ No
???. If Yes, provide details: ___________________
11. Applicant?s Grandparents:
??.? If applicant?s FATHER was born outside of Saint Aldwin, was one of his parents a citizen of the Barony of Saint Aldwin at the time of his birth? _____Yes __X__ No
???. If Yes, provide details: (full name, country and date of birth): ___________________
??.? If applicant?s MOTHER was born outside of Saint Aldwin, was one of her parents a citizen of the Barony of Saint Aldwin at the time of her birth? _____Yes __X__ No
???. If Yes, provide details: (full name, country and date of birth): ___________________
12. Have you ever lived in Saint Aldwin? __X__ Yes _____ No
???. If Yes, have on what date did you enter Saint Aldwin to live?: __12-07-2012__
================================================== =========================
ATTESTATION:
I understand the content of this form. I declare that the information provided is true, correct and complete and that the photographs enclosed are a true likeness of me. I understand that if I make a false declaration or fail to disclose all information material to my application, my citizenship certificate could be taken away and that I could be charged under the Citizenship Act.
Signature of Applicant: __Annie-Love Harper Bertand__
Date: __01-28-2013__
???. Did you receive any assistance in completing this form? _____ Yes __X__ No
???. If Yes, provide full name and address of individual or organization who assisted: ____________
Signature of Assistant: ________________
Date: _________________
================================================== =========================
DOCUMENTATION CHECKLIST:
Send the following documents with your application. Check each box once you enclose the item.
Failure to provide a fully completed application form or the necessary documents will result in the return of your application. If you are sending more than one application (for example, family members), and one of the applications is incomplete, all applications will be returned to you.
If the application is for your first citizenship certificate, provide originals or clear and legible certified copies of your documents.
If the application is for a replacement certificate, provide clear and legible photocopies of your documents.
__X__ Application for a Citizenship Certificate, fully completed, signed and dated. See section ?Step 2. Complete the Application? in the instruction guide to know how to complete the form.
__X__ Two (2) pieces of personal identification, one of which MUST have your photo on it. If there is information on both sides of your personal identification documents, provide a photocopy of both sides.
__X__Two (2) citizenship photos. See ?Citizenship Photographs Specifications? in the instruction guide.
__X__ Fees. Enclose two (2) copies of the Receipt form showing the amount paid. See ?Step 3. Pay the Fees? in the instruction guide for the acceptable methods of payment.
__NA__ Original translation (if applicable) of any documents that are not in French or Common and an affidavit from the translator. See ?Step 1. Gather Documents? in the instruction guide.
INCLUDE THIS COMPLETED DOCUMENT CHECKLIST WITH YOUR APPLICATION PACKAGE.
================================================== ============================
Official use only
DCI no. _____________________
Case ID _____________________
Certificate No. ___________________
_____ Return original documents
_____ Approved
Signature: ____________________________
Date: __________________________
Notify: _________________________________