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pdfOMB No. 1615-0027; Expires 01/31/2012
I-566, Interagency Record of Request
Department of Homeland Security
U.S. Citizenship and Immigration Services
A, G, or NATO Dependent Employment Authorization
or Change/Adjustment To/From A, G, or NATO Status
START HERE - Type or print in black ink.
Part 1. Information About You (The person seeking employment authorization or change/adjustment of status.)
1. Family Name
Given Name
Middle Name
Apt. #
2. Home Address - Street Number and Name
State
City
3. Mailing Address - Street Number and Name
Apt. #
4. Date of Birth (mm/dd/yyyy)
7. Gender
Male
5. Country of Birth
10. U.S. Social Security # (if any)
9. A-Number (if any)
Not Married
11. I-94 # (Arrival-Departure Document)
13. Date of Last Entry into the U.S. (mm/dd/yyyy)
Daytime Phone # (with area code)
6. Country of Citizenship
8. Marital Status
Married
Female
C/O (in care of):
Zip Code
State
City
Zip Code
14. Current Immigration Status
12. DOS Personal Identification # (PID)
15. Relationship to Principal (if applicable)
Part 2. Information About Principal Alien
1. Family Name
Given Name
Middle Name
2. Home Address - Street Number and Name
Apt. #
City
State
3. Date Tour of Duty Expected to End (mm/dd/yyyy)
4. Country of Citizenship
5. Marital Status
Zip Code
Married
6. Job Title
7. I-94 # (Arrival-Departure Document)
Not Married
8. DOS Personal Identification # (PID)
Part 3. Type of Request (See instructions for complete information on the different types of requests.)
1.
I am requesting employment authorization as (select one):
a.
2.
spouse.
b.
son or daughter, age:
, who:
is a full-time, post-secondary student
is disabled
c.
other dependent recognized by the DOS
I am requesting change/adjustment of status (Select one)
a.
Change of nonimmigrant status to A, G, or NATO nonimmigrant - specifically to:
b.
Section 247(a), immigrant to A or G nonimmigrant.
Change to other nonimmigrant status from A, G, or NATO - specifically to:
c.
d.
Adjustment from A, G, or NATO nonimmigrant to immigrant.
e.
A-1, A-2, G-1, or G-2, nonimmigrant applying under Section 13 of the Act of September 11, 1957.
Part 4. Certification (Submit two copies with original signatures - Page 2 must also be attached.)
I certify under penalty of perjury that the foregoing is true and correct. I understand false information is a basis for denial or termination of the
benefit requested and for other penalties provided by law and regulation. If I am requesting employment authorization, I further certify that I do not
have a criminal record. I have not violated United States immigration and/or visa laws, I have not worked illegally in the United States, and I have
paid Social Security and all applicable taxes on all employment in the United States.
Signature of Applicant
Date (mm/dd/yyyy)
Copy 1:USCIS
Copy 2: DOS/NATO/HQ SACT/USUN/VISA OFFICE
Form I-566 (Rev. 01/18/11)Y
Part 5. Your Personal Information
Your Name (family, given, middle)
Date of Birth (mm/dd/yyyy)
DOS Personal Identification # (PID)
For Official Use Only
Part 6. Certification by Diplomatic Mission, International Organization, NATO/HQ SACT, or
NATO Member State (Certifying official must have this information and page to complete process.)
I certify that the information provided on the first page of this Form I-566 is true and correct to the best of my knowledge and
according to our official records.
As an applicant for employment authorization, I further certify that his or her eligibility has been verified under the provisions of:
A bilateral agreement with:
A de facto agreement with:
Check each of the following that apply:
Based on principal alien's G-4 status
Without a numerical limit
With a numerical limit and this applicant is within the limit; and
As an applicant for status as a principal alien, I further
and was notified to the DOS on (date):
certify that he or she is being offered the position of:
Signature of Certifying Officer or Official
Printed Name
Official Seal
Name and Address of Diplomatic Mission, International Organization, NATO/HQ SACT, or
NATO Member State
Duty/Title
Phone Number (include area code)
Date (mm/dd/yyyy)
Part 7. DOS, NATO/HQ SACT, and/or USUN Use Only
1. The Department of State, NATO/HQ SACT, and/or USUN:
Recommends the request be granted
Recommends the request be denied
If the recommendation is for denial, provide a reason(s) for such recommendation:
2. Date (mm/dd/yyyy)
3. Phone Number (include area code)
4. Office:
Protocol
Signature 2
4. Signature 1
USUN
NATO/HQ SACT
Visa
Part 8. USCIS Use Only
1. From:
Adjudicator's Identification #
USCIS Office
Office Phone Number (with area code)
A-Number / File No.
2. To:
Visa Office (Subject filed under Section 13. Please advise USCIS of your findings.)
USUN
Protocol
NATO/HQ SACT
If change of status granted, give new status:
Date of Decision (mm/dd/yyyy)
3. Adjustment or Change of Status:
Granted
Denied
4. Request for Employment Authorization: Date of Decision (mm/dd/yyyy):
Valid to (mm/dd/yyyy): Classification:
Denied
Granted
5. DOS/NATO/HQ SACT/USUN/Visa
Office Notified:
Yes
No
Date of Notification (mm/dd/yyyy):
Copy 1: USCIS
Copy 2: DOS/NATO/HQ SACT/USUN/VISA OFFICE
Form I-566 (Rev. 01/18/11) Y Page 2
OMB No. 1615-0027
I-566, Interagency Record of Request
Department of Homeland Security
U.S. Citizenship and Immigration Services
A, G, or NATO Dependent Employment Authorization
or Change/Adjustment To/From A, G, or NATO Status
START HERE - Type or print in black ink.
Part 1. Information About You (The person seeking employment authorization or change/adjustment of status.)
1. Family Name
Given Name
Middle Name
Apt. #
2. Home Address - Street Number and Name
State
City
3. Mailing Address - Street Number and Name
Apt. #
4. Date of Birth (mm/dd/yyyy)
7. Gender
Male
5. Country of Birth
10. U.S. Social Security # (if any)
9. A-Number (if any)
Not Married
11. I-94 # (Arrival-Departure Document)
13. Date of Last Entry into the U.S. (mm/dd/yyyy)
Daytime Phone # (with area code)
6. Country of Citizenship
8. Marital Status
Married
Female
C/O (in care of):
Zip Code
State
City
Zip Code
14. Current Immigration Status
12. DOS Personal Identification # (PID)
15. Relationship to Principal (if applicable)
Part 2. Information About Principal Alien
1. Family Name
Given Name
Middle Name
2. Home Address - Street Number and Name
Apt. #
City
State
3. Date Tour of Duty Expected to End (mm/dd/yyyy)
4. Country of Citizenship
5. Marital Status
Zip Code
Married
6. Job Title
7. I-94 # (Arrival-Departure Document)
Not Married
8. DOS Personal Identification # (PID)
Part 3. Type of Request (See instructions for complete information on the different types of requests.)
1.
I am requesting employment authorization as (select one):
a.
2.
spouse.
b.
son or daughter, age:
, who:
is a full-time, post-secondary student
is disabled
c.
other dependent recognized by the DOS
I am requesting change/adjustment of status (Select one)
a.
Change of nonimmigrant status to A, G, or NATO nonimmigrant - specifically to:
b.
Section 247(a), immigrant to A or G nonimmigrant.
Change to other nonimmigrant status from A, G, or NATO - specifically to:
c.
d.
Adjustment from A, G, or NATO nonimmigrant to immigrant.
e.
A-1, A-2, G-1, or G-2, nonimmigrant applying under Section 13 of the Act of September 11, 1957.
Part 4. Certification (Submit two copies with original signatures - Page 2 must also be attached.)
I certify under penalty of perjury that the foregoing is true and correct. I understand false information is a basis for denial or termination of the
benefit requested and for other penalties provided by law and regulation. If I am requesting employment authorization, I further certify that I do not
have a criminal record. I have not violated United States immigration and/or visa laws, I have not worked illegally in the United States, and I have
paid Social Security and all applicable taxes on all employment in the United States.
Signature of Applicant
Date (mm/dd/yyyy)
Copy 1:USCIS
Copy 2: DOS/NATO/HQ SACT/USUN/VISA OFFICE
Form I-566 (Rev. 01/18/11)Y
Part 5. Your Personal Information
Your Name (family, given, middle)
Date of Birth (mm/dd/yyyy)
DOS Personal Identification # (PID)
For Official Use Only
Part 6. Certification by Diplomatic Mission, International Organization, NATO/HQ SACT, or
NATO Member State (Certifying official must have this information and page to complete process.)
I certify that the information provided on the first page of this Form I-566 is true and correct to the best of my knowledge and
according to our official records.
As an applicant for employment authorization, I further certify that his or her eligibility has been verified under the provisions of:
A bilateral agreement with:
A de facto agreement with:
Check each of the following that apply:
Based on principal alien's G-4 status
Without a numerical limit
With a numerical limit and this applicant is within the limit; and
As an applicant for status as a principal alien, I further
and was notified to the DOS on (date):
certify that he or she is being offered the position of:
Signature of Certifying Officer or Official
Printed Name
Official Seal
Name and Address of Diplomatic Mission, International Organization, NATO/HQ SACT, or
NATO Member State
Duty/Title
Phone Number (include area code)
Date (mm/dd/yyyy)
Part 7. DOS, NATO/HQ SACT, and/or USUN Use Only
1. The Department of State, NATO/HQ SACT, and/or USUN:
Recommends the request be granted
Recommends the request be denied
If the recommendation is for denial, provide a reason(s) for such recommendation:
2. Date (mm/dd/yyyy)
3. Phone Number (include area code)
4. Office:
Protocol
Signature 2
4. Signature 1
USUN
NATO/HQ SACT
Visa
Part 8. USCIS Use Only
1. From:
Adjudicator's Identification #
USCIS Office
Office Phone Number (with area code)
A-Number / File No.
2. To:
Visa Office (Subject filed under Section 13. Please advise USCIS of your findings.)
USUN
Protocol
NATO/HQ SACT
If change of status granted, give new status:
Date of Decision (mm/dd/yyyy)
3. Adjustment or Change of Status:
Granted
Denied
4. Request for Employment Authorization:
Denied
Granted
Date of Decision (mm/dd/yyyy):
5. DOS/NATO/HQ SACT/USUN/Visa
Office Notified:
Yes
No
Date of Notification (mm/dd/yyyy):
Valid to (mm/dd/yyyy):
Copy 1: USCIS
Copy 2: DOS/NATO/HQ SACT/USUN/VISA OFFICE
Classification:
Form I-566 (Rev. 01/18/11) Y Page 2
| File Type | application/pdf |
| File Title | Interagency Record of Request - A, G, or NATO Dependent Employment Authorization or Change/Adjustment To/From A. G, or NATO Stat |
| Author | USCIS |
| File Modified | 2012-01-10 |
| File Created | 2006-03-29 |