Form I-212 Application for Permission to Reapply for Admission into

OMB No. 1615-0018; Exp. 06/30/2010

I-212, Application for Permission to Reapply for Admission
Into the United States After Deportation or Removal

Department of Homeland Security
U.S. Citizenship and Immigration Services

Fee Stamp

(To be filed in duplicate)
Date (mm/dd/yyyy)
I request permission to reapply for admission into the United States.
1. Name

( Last)

(First)

(Middle)

2. File numbers on correspondence from U.S. Citizenship and Immigration
Services (USCIS) or former Immigration and Naturalization Service
(INS) (if known)

3. Name used when last deported or removed from the U.S.

4. Date of Birth (mm/dd/yyyy)

5. Other names used or known by

6a. Place of Birth (city or town; state or province; and country)

7. Circumstances under which deported or removed from the United
States (Check applicable blocks)

6b. Country of Citizenship/Nationality

Excluded and deported or removed. (less than one year ago)
8. Length of residence in the United States (years)
Arrested and deported or removed. (less than five years ago)
Removed after having fallen into distress. (less than five years ago) 9. Place of residence at time of deportation or removal from United States
(city and state)
Removed as alien enemy. (less than five years ago)
Removed at U.S. Government expense in lieu of deportation.
(less than five years ago)
10. Place deportation hearing held or application for removal made (city)
11. Country to which deported or removed

12. Detention facility or jail where detained (city and state) (If not
detained, write "None")

13. Date of deportation or removal from United States (mm/dd/yyyy)

14. Port of departure from United States

15. Status desired if permitted to re-enter United States

16. Reasons for desiring to re-enter the United States

Permanent Resident

Visitor

Student

Other (specify)
17. Location of American Embassy/Consulate where application for visa
will be made (city and country)

18. Name and relationship of U.S. citizen or lawful permanent resident
alien spouse, parent or children, if any

19. Signature of Applicant

20. Street and number; city or town; state or province; and country of
present residence

Signature of person preparing form, if other than applicant.

21. I declare that this document was prepared by me at the request of the applicant and is based on all information of which I have any knowledge.
(Signature)

This space for use by DHS officer
File A Decision

Complete and Submit Both Forms.

(Address)

(Date)

Date of
Action
DD
or
OIC
Office
RECEIVED

TRANS. IN

RET'D-TRANS.-OUT

COMPLETED

Form I-212 (Rev. 07/30/07)Y

I-212, Application for Permission to Reapply for Admission
Into the United States After Deportation or Removal

Department of Homeland Security
U.S. Citizenship and Immigration Services

Fee Stamp

(To be filed in duplicate)
Date (mm/dd/yyyy)
I request permission to reapply for admission into the United States.
1. Name

( Last)

(First)

(Middle)

2. File numbers on correspondence from U.S. Citizenship and Immigration
Services (USCIS) or former Immigration and Naturalization Service
(INS) (if known)

3. Name used when last deported or removed from the U.S.

4. Date of Birth (mm/dd/yyyy)

5. Other names used or known by

6a. Place of Birth (city or town; state or province; and country)

7. Circumstances under which deported or removed from the United
States (Check applicable blocks)

6b. Country of Citizenship/Nationality

Excluded and deported or removed. (less than one year ago)
8. Length of residence in the United States (years)
Arrested and deported or removed. (less than five years ago)
Removed after having fallen into distress. (less than five years ago) 9. Place of residence at time of deportation or removal from United States
(city and state)
Removed as alien enemy. (less than five years ago)
Removed at U.S. Government expense in lieu of deportation.
(less than five years ago)
10. Place deportation hearing held or application for removal made (city)
11. Country to which deported or removed

12. Detention facility or jail where detained (city and state) (If not
detained, write "None")

13. Date of deportation or removal from United States (mm/dd/yyyy)

14. Port of departure from United States

15. Status desired if permitted to re-enter United States

16. Reasons for desiring to re-enter the United States

Permanent Resident

Visitor

Student

Other (specify)
17. Location of American Embassy/Consulate where application for visa
will be made (city and country)

18. Name and relationship of U.S. citizen or lawful permanent resident
alien spouse, parent or children, if any

19. Signature of Applicant

20. Street and number; city or town; state or province; and country of
present residence

Signature of person preparing form, if other than applicant.

21. I declare that this document was prepared by me at the request of the applicant and is based on all information of which I have any knowledge.
(Signature)

This space for use by DHS officer
File A Decision

Complete and Submit Both Forms.

(Address)

(Date)

Date of
Action
DD
or
OIC
Office
RECEIVED

TRANS. IN

RET'D-TRANS.-OUT

COMPLETED

Form I-212 (Rev. 07/30/07)Y