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2. PRIVATE EMPLOYER AFFIDAVIT 

   This form MUST be completed.  If you select "Option A" you must list your Federal Work Program Authorization Number and the Date of Authorization. All forms must be signed by an authorized officer or agent of the business and notarized. 

   Private Employer Affidavit Pursuant to O.C.G.A. §36-60-6(d) 

   By executing this affidavit under oath, as an applicant for a Business License as referenced in O.C.G.A. §36 -60 -6(d), from Greene County, Georgia, the undersigned applicant representing the private employer known as 

4. Name of Business

6. verifies one of the following with respect to the application for the above mentioned document:

8. Total Number of Employees

   1. (Option A) 1 - 10 Employees
   2. (Option B) 11 or More Employees
10. Federal Work Authorization User Identification Number

    The employer has registered with and utilizes the federal work authorization program in accordance with the applicable provisions and deadlines established in O.C.G.A. §36-60-6. The undersigned private employer also attests that its federal work authorization user identification number (NOT YOUR FEDERAL TAX ID NUMBER) and date of authorization are as listed above:

    
    

11. Date of Authorization

13. ALL FORMS MUST BE SIGNED AND NOTARIZED.

    In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of O.C.G.A. §16- 10-20, and face criminal penalties allowed by such statute. 

    Executed on the______ day of ___________________, 20____ in,___________________________________

    
    

    ___________________________________________________________________
    Signature of Authorized Officer or Agent

    ___________________________________________________________________
    Printed Name of and Title of Authorized Officer or Agent 

    
    

    SUBSCRIBED AND SWORN BEFORE ME ON THIS THE _______ DAY OF _______________________, 20________

    
    

    ___________________________________________________________________
    Notary Public

    
    

    ___________________________________________________________________
    My Commission Expires

    
    

    
    

    AFFIX SEAL

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