Private Employer Affidavit

Instruction for completing the Private Employer Affidavit

Answer all questions in the application.  For those questions that do not apply, enter "N/A".

Print the application using the print button on the last page of the application. 

Make sure that the application is SIGNED and NOTARIZED.  

If you are having difficulty completing the online form, download and complete the PDF version of the Private Employer Affidavit (PDF). 

Private Employer Affidavit

  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 

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

  8. Total Number of Employees

  10. 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:


  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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