Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696512186645.pdf (United States)
COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF STATE BUREAU OF PROFESSIONAL AND OCCUPATIONAL AFFAIRS P.O.
BOX 2649 HARRISBURG, PA 17105 WAIVER OF SOCIAL SECURITY NUMBER VERIFICATION STATEMENT Name: _______________________________________________________________ Last First Middle Profession: ___________________________________________________________ This is to verify that I do not have a social security number for the following reason (s): _____________________________________________________________________ I verify that the statement made above is true and correct to the best of my knowledge, information and belief.
I understand that false statements are made subject to the penalties of 18 Pa. C.S.

Section 4904 relating to unsworn falsification to authorities and may result in the suspension or revocation of my license.

I also acknowledge that I will provide the Board with my Social Security Number as soon as it is obtained.

Further, I understand that I will not be permitted to renew my license until I have submitted my Social Security Number to the Board.

Signature Date