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pdfUSCIS
Form I-765
Application For Employment Authorization
Department of Homeland Security
U.S. Citizenship and Immigration Services
Authorization/Extension
Valid From
For
USCIS
Use
Only
Fee Stamp
OMB No. 1615-0040
Expires 07/31/2022
Action Block
Authorization/Extension
Valid Through
Alien Registration Number
A-
Remarks
To be completed by an attorney or
Board of Immigration Appeals (BIA)accredited representative (if any).
Select this box if Form G-28
is attached.
Attorney or Accredited Representative
USCIS Online Account Number (if any)
► START HERE - Type or print in black ink. Answer all questions fully and accurately. If a question does not apply to you (for
example, if you have never been married and the question asks, “Provide the name of your current spouse”), type or print “N/A”
unless otherwise directed. If your answer to a question which requires a numeric response is zero or none (for example, “How
many children do you have” or “How many times have you departed the United States”), type or print “None” unless otherwise
directed.
Part 1. Reason for Applying
Other Names Used
I am applying for (select only one box):
Provide all other names you have ever used, including aliases,
maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 6.
Additional Information.
1.a.
Initial permission to accept employment.
1.b.
Replacement of lost, stolen, or damaged employment
authorization document, or correction of my
employment authorization document NOT DUE to
U.S. Citizenship and Immigration Services (USCIS)
error.
1.c.
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
NOTE: Replacement (correction) of an employment
authorization document due to USCIS error does not
require a new Form I-765 and filing fee. Refer to
Replacement for Card Error in the What is the
Filing Fee section of the Form I-765 Instructions for
further details.
2.c. Middle Name
Renewal of my permission to accept employment.
(Attach a copy of your previous employment
authorization document.)
3.c. Middle Name
Part 2. Information About You
Your Full Legal Name
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c. Middle Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
Form I-765 Edition 08/25/20
Page 1 of 7
14.
Part 2. Information About You (continued)
Your U.S. Mailing Address
(USPS ZIP Code Lookup)
5.a. In Care Of Name (if any)
NOTE: If you answered “No” to Item Number 14., skip
to Part 2., Item Number 18.a. If you answered “Yes” to
Item Number 14., you must also answer “Yes” to Item
Number 15.
5.b. Street Number
and Name
5.c.
Apt.
Ste.
15.
Flr.
5.d. City or Town
5.e. State
6.
5.f.
ZIP Code
Is your current mailing address the same as your physical
address?
Yes
No
NOTE: If you answered “No” to Item Number 6.,
provide your physical address below.
Ste.
16.a. Family Name
(Last Name)
16.b. Given Name
(First Name)
Flr.
Mother's Name
7.c. City or Town
7.d. State
Provide your mother's birth name.
17.a. Family Name
(Last Name)
17.b. Given Name
(First Name)
7.e. ZIP Code
Other Information
8.
Alien Registration Number (A-Number) (if any)
► A-
9.
USCIS Online Account Number (if any)
►
10.
Gender
11.
Marital Status
Single
12.
NOTE: If you answered “Yes” to Item Numbers
14. - 15., provide the information requested in Item
Numbers 16.a. - 17.b.
Provide your father's birth name.
7.a. Street Number
and Name
Apt.
Consent for Disclosure: I authorize disclosure of
information from this application to the SSA as required
for the purpose of assigning me an SSN and issuing me a
Social Security card.
Yes
No
Father's Name
U.S. Physical Address
7.b.
Do you want the SSA to issue you a Social Security card?
(You must also answer “Yes” to Item Number 15.,
Consent for Disclosure, to receive a card.)
Yes
No
Male
Married
Divorced
Your Country or Countries of Citizenship or
Nationality
Female
Widowed
List all countries where you are currently a citizen or national.
If you need extra space to complete this item, use the space
provided in Part 6. Additional Information.
18.a. Country
18.b. Country
Have you previously filed Form I-765?
Yes
No
13.a. Has the Social Security Administration (SSA) ever
officially issued a Social Security card to you?
Yes
No
NOTE: If you answered “No” to Item Number 13.a.,
skip to Item Number 14. If you answered “Yes” to Item
Number 13.a., provide the information requested in Item
Number 13.b.
13.b. Provide your Social Security number (SSN) (if known).
►
Form I-765 Edition 08/25/20
Page 2 of 7
Part 2. Information About You (continued)
Information About Your Eligibility Category
27.
Place of Birth
List the city/town/village, state/province, and country where
you were born.
Eligibility Category. Refer to the Who May File Form
I-765 section of the Form I-765 Instructions to determine
the appropriate eligibility category for this application.
Enter the appropriate letter and number for your eligibility
category below (for example, (a)(8), (c)(17)(iii)).
19.a. City/Town/Village of Birth
(
28.
19.b. State/Province of Birth
)(
)(
)
(c)(3)(C) STEM OPT Eligibility Category. If you
entered the eligibility category (c)(3)(C) in Item Number
27., provide the information requested in Item Numbers
28.a. - 28.c.
19.c. Country of Birth
28.a. Degree
28.b. Employer's Name as Listed in E-Verify
20.
Date of Birth (mm/dd/yyyy)
Information About Your Last Arrival in the
United States
28.c. Employer's E-Verify Company Identification Number or a
Valid E-Verify Client Company Identification Number
21.a. Form I-94 Arrival-Departure Record Number (if any)
►
29.
21.b. Passport Number of Your Most Recently Issued Passport
►
21.c. Travel Document Number (if any)
30.
21.d. Country That Issued Your Passport or Travel Document
21.e. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
(c)(26) Eligibility Category. If you entered the eligibility
category (c)(26) in Item Number 27., provide the receipt
number of your H-1B spouse's most recent Form I-797
Notice for Form I-129, Petition for a Nonimmigrant
Worker.
(c)(8) Eligibility Category If you entered the eligibility
category (c)(8) in Item Number 27., provide the
information requested in Item Numbers 30.a. - 30.g.
30.a. Have you EVER been arrested for, and/or charged with,
and/or convicted of any crime in any country?
Yes
22.
Date of Your Last Arrival Into the United States, On or
About (mm/dd/yyyy)
23.
Place of Your Last Arrival Into the United States
24.
Immigration Status at Your Last Arrival (for example,
B-2 visitor, F-1 student, or no status)
25.
Your Current Immigration Status or Category (for example,
B-2 visitor, F-1 student, parolee, deferred action, or no
status or category)
26.
Student and Exchange Visitor Information System
(SEVIS) Number (if any)
► N-
Form I-765 Edition 08/25/20
No
NOTE: If you answered “Yes” to Item Number 30.a.,
refer to Special Filing Instructions for Those With
Pending Asylum Applications (c)(8) of the Form I-765
Instructions for information about providing court
dispositions.
30.b. Did you enter the United States lawfully through a U.S.
port of entry and were you inspected and admitted or
paroled after inspection by an immigration officer? (If
you answer “Yes,” you MUST provide evidence of your
lawful entry.)
Yes
No
30.c. If you answered “No” to Item Number 30.b., did you
present yourself to the Secretary of Homeland Security or
his or her delegate (DHS) within 48 hours of entry or
attempted entry AND express an intention to seek asylum
within the United States or express a fear of persecution
or torture in your home country?
Yes
No
Page 3 of 7
Part 2. Information About You (continued)
If you answered “Yes” to Item Number 30.c., provide the
following information:
30.d. Date you presented yourself to DHS
Part 3. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature
NOTE: Read the Penalties section of the Form I-765
Instructions before completing this section. You must file
Form I-765 while in the United States.
30.e. Location where you presented yourself to DHS
Applicant's Statement
30.f. Country of claimed persecution
30.g. Provide an explanation for why you did not enter the
United States lawfully through a U.S. port of entry. If
you need extra space to complete this item, use the space
provided in Part 6. Additional Information.
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
1.a.
I can read and understand English, and I have read
and understand every question and instruction on this
application and my answer to every question.
1.b.
The interpreter named in Part 4. read to me every
question and instruction on this application and my
answer to every question in
,
a language in which I am fluent, and I understood
everything.
2.
At my request, the preparer named in Part 5.,
,
prepared this application for me based only upon
information I provided or authorized.
NOTE: Refer to the Special Filing Instructions for Those
With Pending Asylum Applications (c)(8) section of the Form
I-765 Instructions for more information.
31.a. (c)(35) and (c)(36) Eligibility Category. If you entered
the eligibility category (c)(35) in Item Number 27., please
provide the receipt number of your Form I-797 Notice for
Form I-140, Immigrant Petition for Alien Worker. If you
entered the eligibility category (c)(36) in Item Number
27., please provide the receipt number of your spouse's or
parent's Form I-797 Notice for Form I-140.
►
31.b. If you entered the eligibility category (c)(35) or (c)(36) in
Item Number 27., have you EVER been arrested for
and/or convicted of any crime?
Yes
No
NOTE: If you answered “Yes” to Item Number 31.b.,
refer to Employment-Based Nonimmigrant Categories,
Items 8. - 9., in the Who May File Form I-765 section of
the Form I-765 Instructions for information about
providing court dispositions.
Applicant's Contact Information
3.
Applicant's Daytime Telephone Number
4.
Applicant's Mobile Telephone Number (if any)
5.
Applicant's Email Address (if any)
6.
Select this box if you are a Salvadoran or Guatemalan
national eligible for benefits under the ABC
settlement agreement.
Applicant's Declaration and Certification
Copies of any documents I have submitted are exact photocopies
of unaltered, original documents, and I understand that USCIS
may require that I submit original documents to USCIS at a later
date. Furthermore, I authorize the release of any information
from any and all of my records that USCIS may need to
determine my eligibility for the immigration benefit that I seek.
I furthermore authorize release of information contained in this
application, in supporting documents, and in my USCIS
records, to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
Form I-765 Edition 08/25/20
Page 4 of 7
Part 3. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
I understand that USCIS may require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, if I am required to provide
biometrics, I will be required to sign an oath reaffirming that:
Part 4. Interpreter's Contact Information,
Certification, and Signature
Interpreter's Mailing Address
3.a. Street Number
and Name
3.b.
Apt.
1) I reviewed and understood all of the information
contained in, and submitted with, my application; and
3.c. City or Town
2) All of this information was complete, true, and correct
at the time of filing.
3.d. State
Ste.
Flr.
3.e. ZIP Code
I certify, under penalty of perjury, that all of the information in
my application and any document submitted with it were
provided or authorized by me, that I reviewed and understand
all of the information contained in, and submitted with, my
application and that all of this information is complete, true, and
correct.
3.f.
Applicant's Signature
Interpreter's Contact Information
7.a. Applicant's Signature
4.
Interpreter's Daytime Telephone Number
7.b. Date of Signature (mm/dd/yyyy)
5.
Interpreter's Mobile Telephone Number (if any)
NOTE TO ALL APPLICANTS: If you do not completely fill
out this application or fail to submit required documents listed
in the Instructions, USCIS may deny your application.
6.
Interpreter's Email Address (if any)
Part 4. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter.
Interpreter's Full Name
1.a. Interpreter's Family Name (Last Name)
1.b. Interpreter's Given Name (First Name)
2.
Interpreter's Business or Organization Name (if any)
Province
3.g. Postal Code
3.h. Country
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
,
which is the same language specified in Part 3., Item Number
1.b., and I have read to this applicant in the identified language
every question and instruction on this application and his or her
answer to every question. The applicant informed me that he or
she understands every instruction, question, and answer on the
application, including the Applicant's Declaration and
Certification, and has verified the accuracy of every answer.
Interpreter's Signature
7.a. Interpreter's Signature
7.b. Date of Signature (mm/dd/yyyy)
Form I-765 Edition 08/25/20
Page 5 of 7
Part 5. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, If Other Than the Applicant
Preparer's Statement
7.a.
I am not an attorney or accredited representative but
have prepared this application on behalf of the
applicant and with the applicant's consent.
7.b.
I am an attorney or accredited representative and my
representation of the applicant in this case
extends
does not extend beyond the
preparation of this application.
Provide the following information about the preparer.
Preparer's Full Name
1.a. Preparer's Family Name (Last Name)
1.b. Preparer's Given Name (First Name)
2.
Preparer's Business or Organization Name (if any)
NOTE: If you are an attorney or accredited
representative, you need to submit a completed
Form G-28, Notice of Entry of Appearance as
Attorney or Accredited Representative, with this
application.
Preparer's Certification
Preparer's Mailing Address
3.a. Street Number
and Name
3.b.
Apt.
Ste.
Flr.
3.c. City or Town
3.d. State
3.f.
3.e. ZIP Code
Province
3.g. Postal Code
By my signature, I certify, under penalty of perjury, that I
prepared this application at the request of the applicant. The
applicant then reviewed this completed application and
informed me that he or she understands all of the information
contained in, and submitted with, his or her application,
including the Applicant's Declaration and Certification, and
that all of this information is complete, true, and correct. I
completed this application based only on information that the
applicant provided to me or authorized me to obtain or use.
Preparer's Signature
8.a. Preparer's Signature
3.h. Country
8.b. Date of Signature (mm/dd/yyyy)
Preparer's Contact Information
4.
Preparer's Daytime Telephone Number
5.
Preparer's Mobile Telephone Number (if any)
6.
Preparer's Email Address (if any)
Form I-765 Edition 08/25/20
Page 6 of 7
5.a. Page Number
Part 6. Additional Information
If you need extra space to provide any additional information
within this application, use the space below. If you need more
space than what is provided, you may make copies of this page to
complete and file with this application or attach a separate sheet
of paper. Type or print your name and A-Number (if any) at the
top of each sheet; indicate the Page Number, Part Number, and
Item Number to which your answer refers; and sign and date
each sheet.
5.b. Part Number
5.c. Item Number
6.b. Part Number
6.c. Item Number
7.b. Part Number
7.c. Item Number
5.d.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.
A-Number (if any) ► A-
3.a. Page Number
3.b. Part Number
3.c. Item Number
3.d.
4.a. Page Number
6.a. Page Number
6.d.
4.b. Part Number
4.d.
Form I-765 Edition 08/25/20
4.c. Item Number
7.a. Page Number
7.d.
Page 7 of 7