Form I-765 Application for Employment Authorization

OMB No. 1615-0040; Expires 04/30/2013

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

until

Application Approved. Employment Authorized / Extended (Circle One)

(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 under 8 CFR 274a.12(c)(14), (18) and 8 CFR 214.2(f)
I am applying for:

Not For
Production
08/08/12
Final

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)

Which USCIS Office?

(Middle)

Results (Granted or Denied - attach all documentation)

2. Other Names Used (include Maiden Name)

3. Address in the United States (Street Number and Name)
(Town or City)

(State/Country)

(Apt. Number)

12. Date of Last Entry into the U.S.

(ZIP Code)

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

6. Date of Birth

(State/Province)

(mm/dd/yyyy)

15. Current Immigration Status (Visitor, Student, etc.)

(Country)

16. Go to the “Who May File Form I-765?” section of the instructions. In the
space below, place the letter and number of the eligibility category you
selected from the instructions. (For example, (a)(8), (c)(17)(iii), etc.).

7. Gender

Male

8. Marital Status

(mm/dd/yyyy)

14. Manner of Last Entry (Visitor, Student, etc.)

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

Date(s)

Female

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

)

(

(

)

)

(

17. If you entered the eligibility category, (c)(3)(C), in Question 16 above, list your
degree, your employer's name as listed in E-Verfy, and your employer's EVerify Company Identification Number or a valid E-Verify Client Company
Identification Number in the space below.

10. Alien Registration Number (A-Number) or I-94 Number (if any)

Degree:

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

No

Yes (If "Yes," complete below)

Employer's Name as listed in E-Verify:

Employer's E-Verify Company Identification Number or a valid E-Verify
Client Company Identification Number

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 U.S. Citizenship and Immigration Services needs to determine
eligibility for the benefit I am seeking. I have read the “Who May File Form I-765?” section of the instructions and have identified
the appropriate eligibility category in Question 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

Date

Relocated
Received

Sent

Approved

Completed
Denied

Returned

Form I-765 08/08/12 Y