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

DRAFT
Form I-212, Application for Permission to Reapply for Admission

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

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

Into the United States After Deportation or Removal

For Government Use Only
Fee Stamp

RECEIVED

RET'D-TRANS.-OUT

TRANS. IN

COMPLETED

Date

This space for use by DHS officer

Date of
Action

File A Decision

DD
or
OIC
Office

Applicants Start Here (To be filed in duplicate)
PART I. INFORMATION ABOUT YOU
First Name

Last Name

Middle Name

Alien registration number (A#) if known, or Alien File(s) or receipt number(s) and any immigration file(s)
or case number(s) listed on correspondence from U.S. immigration authorities that relate to you

Other names used or known by

Place of Birth (City or Town)

Name used when last deported or removed
from the United States

State

Country of Citizenship
or Nationality

Province

Date of Birth

Country

PART II. REASON FOR FILING THIS FORM
I am inadmissible to the United States for the following reason(s) and no others:
I have been removed as an arriving alien in expedited removal proceedings under INA section 235(b)(1), or I was removed
at the end of proceedings under INA section 240 as an arriving alien (INA section 212(a)(9)(A)(i)).
I have only been removed once, and my last removal was less than 5 years ago.
I have been removed at least twice or more, and my last removal was less than 20 years ago.
I have been convicted of an aggravated felony (in the United States or elsewhere, before or after my removal from the
United States).
I have been removed as a deportable alien under INA section 240 or any other provision of the law, or I departed the
United States while an order or removal was outstanding (INA section 212(a)(9)(A)(ii)).
I have only been removed once and less than 10 years ago.
I have been removed at least twice or more, and my last removal was less than 20 years ago.
I have been convicted of an aggravated felony (in the United States or elsewhere, before or after my removal from the
United States).
Form I-212 (Rev. 02/02/10)N

I entered or attempted to enter the United States without being admitted or paroled after having been removed (INA
section 212(a)(9)(C)(i)(I)).
Specify date of last departure from the United States after having become inadmissible: (Attach evidence that demonstrates the
date of your last departure from the United States and that you have remained outside the United States for 10 years.)

I entered or attempted to enter the United States without being admitted or paroled after having been unlawfully
present in the United States for a period of more than 1 year, in the aggregate (INA section 212(a)(9)(C)(i)(I)).
Specify date of last departure from the United States after having become inadmissible: (Attach evidence that demonstrates the
date of your last departure from the United States and that you have remained outside the United States for 10 years.)

PART III. INFORMATION ABOUT YOUR REMOVAL/DEPORTATION AND DEPARTURE
Date of deportation or removal
from the United States

If you have not been in removal proceedings, date of last
departure from the United States (Attach evidence)

Place of residence at time of deportation or
removal from United States (city and state)

Place deportation or removal hearing held or
application for removal made (city and state)

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

Length of residence in the
United States (years)

Country to which deported or
removed

Port/location of departure from the United States

PART IV. REASON(S) FOR YOUR REQUEST FOR PERMISSION TO REAPPLY
Status desired if permitted to reenter the United States:
Permanent Resident

Visitor

Student

Other (specify)

Reason(s) for desiring to reenter the United States:

Form I-212 (Rev. 02/02/10)N Page 2

REASON(S) FOR YOUR REQUEST FOR PERMISSION TO REAPPLY (Cont'd)
Location of U.S. Embassy/consulate where application for visa is/or will be made (city and country)

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

PART V. APPLICANT'S SIGNATURE AND CERTIFICATION
I certify under penalty of perjury under the laws of the United States that this application and the evidence submitted with it are all
true and correct to the best of my knowledge and abilities. I authorize the release of any information from my records that U.S.
Citizenship and Immigration Services (USCIS) or any other agency adjudicating this application needs to determine my eligibility for
the benefits sought with this application.
Signature of Applicant or Legal Guardian

Date of Signature

Applicant's Street Address (You must provide
a physical address.)

P.O. Box (If applicable)

State

Applicant's Mobile Telephone Number

City

Province

State

Zip Code

Province

Applicant's Telephone Number

Country

Applicant's E-mail Address (if any)

PART VI. PREPARER'S SIGNATURE AND CERTIFICATION (If other than applicant)
I declare that this document was prepared by me at the request of the applicant or legal guardian of the applicant, and that is based on
all information of which I have knowledge and/or was provided to me by the above named person in response to the exact questions
contained on this form. I have not knowingly withheld any information.
Signature of Preparer

Date of Signature

Preparer's Street Address

State

City

P.O. Box (If applicable)

State

Preparer's Mobile Telephone Number

Province

Country

Zip Code

Province

Preparer's Telephone Number

Preparer's E-mail Address (if any)

Form I-212 (Rev. 02/02/10)N Page 3