I-765 Application for Employment Authorization

OMB No. 1615-0040; Expires 08/31/08

I-765, Application for
Employment Authorization

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

Do not write in this block.
Action Block

Remarks

Fee Stamp

A#
Applicant is filing under §274a.12

Application Approved. Employment Authorized / Extended (Circle One)

until

(Date).
(Date).

Subject to the following conditions:
Application Denied.
Failed to establish eligibility under 8 CFR 274a.12 (a) or (c).
Failed to establish economic necessity as required in 8 CFR 274a.12(c)(14), (18) and 8 CFR 214.2(f)
I am applying for:

Permission to accept employment.
Replacement (of lost employment authorization document)
Renewal of my permission to accept employment (attach previous employment authorization document).

1. Name (Family Name in CAPS) (First)

11. Have you ever before applied for employment authorization from USCIS?

(Middle)

No

Yes (If yes, complete below)
Which USCIS Office?

2. Other Names Used (Include Maiden Name)
3. Address in the United States (Number and Street)
(Town or City)

(Apt. Number)

(State/Country)

(ZIP Code)

4. Country of Citizenship/Nationality
5. Place of Birth (Town or City)
6. Date of Birth

(mm/dd/yyyy)

Date(s)

Results (Granted or Denied - attach all documentation)
12. Date of Last Entry into the U.S.

(mm/dd/yyyy)

13. Place of Last Entry into the U.S.

(State/Province)

(Country)

7. Gender
Male

14. Manner of Last Entry (Visitor, Student, etc.)
15. Current Immigration Status (Visitor, Student, etc.)

Female

8. Marital Status

Single
Married
Widowed
Divorced
9. Social Security Number (Include all numbers you have ever used) (if any)

16. Go to Part 2 of the Instructions, Eligibility Categories. In the space below, place
the letter and number of the category you selected from the instructions (For
example, (a)(8), (c)(17)(iii), etc.).

Eligibility under 8 CFR 274a.12
10. Alien Registration Number (A-Number) or I-94 Number (if any)

(

)

(

)

(

)

Certification.
Your Certification: I certify, under penalty of perjury under the laws of the United States of America, that the foregoing is true and
correct. Furthermore, I authorize the release of any information that the U.S. Citizenship and Immigration Services needs to determine
eligibility for the benefit I am seeking. I have read the Instructions in Part 2 and have identified the appropriate eligibility category in
Block 16.
Signature

Telephone Number

Date

Signature of person preparing form, if other than above: 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.
Print Name

Remarks

Signature

Address

Initial Receipt

Resubmitted

Relocated
Rec'd
Sent

Date

Approved

Completed
Denied

Returned

Form I-765 (Rev. 07/30/07)N