G-28 Notice of Entry of Appearance as Attorney or Accredited

Notice of Entry of Appearance
as Attorney or Accredited Representative

DHS
Form G-28

Department of Homeland Security

OMB No. 1615-0105
Expires 02/28/2017

Part 1. Information About Attorney or
Accredited Representative

Part 2. Notice of Appearance as Attorney or
Accredited Representative

1.

This appearance relates to immigration matters before
(Select only one box):

USCIS ELIS Account Number (if any)
►

DRAFT
NOT
FOR
PRODUCTION
02/25/2015
1.a.

USCIS

Name and Address of Attorney or Accredited
Representative

1.b. List the form numbers

2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)

2.a.

ICE

2.b. List the specific matter in which appearance is entered

2.c. Middle Name

3.a. Street Number
and Name
3.b. Apt.

3.a.

Ste.

Flr.

CBP

3.b. List the specific matter in which appearance is entered

3.c. City or Town
3.d. State

3.e. ZIP Code

I enter my appearance as attorney or accredited representative at
the request of:
4.

3.f.

Province

Applicant

3.g. Postal Code
3.h. Country

4.

Daytime Telephone Number

5.

Fax Number

6.

E-Mail Address (if any)

7.

Mobile Telephone Number (if any)

Select only one box:

Petitioner

Requestor

Respondent (ICE, CBP)

Information About Applicant, Petitioner,
Requestor, or Respondent

5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)

5.c. Middle Name

Form G-28 02/25/15 N

6.

Name of Company or Organization (if applicable)

Page 1 of 4

Part 2. Notice of Appearance as Attorney or
Accredited Representative (continued)

Part 3. Eligibility Information for Attorney or
Accredited Representative

Information About Applicant, Petitioner,
Requestor, or Respondent (continued)

Select all applicable items.

7.

1.a.

USCIS ELIS Account Number (if any)
►

8.

I am an attorney eligible to practice law in, and a
member in good standing of, the bar of the highest
courts of the following states, possessions, territories,
commonwealths, or the District of Columbia. (If you
need additional space, use Part 6.)

DRAFT
NOT
FOR
PRODUCTION
02/25/2015

Alien Registration Number (A-Number) or Receipt Number

Licensing Authority

9.

Daytime Telephone Number

1.b. Bar Number (if applicable)

10.

Mobile Telephone Number (if any)

1.c. Name of Law Firm

11.

E-Mail Address (if any)

Mailing Address of Applicant, Petitioner,
Requestor, or Respondent

NOTE: Provide the mailing address of the applicant, petitioner,
requestor, or respondent. If the applicant, petitioner, requestor,
or respondent has used a safe mailing address on the application,
petition, or request being filed with this Form G-28, provide it in
these spaces.
12.a. Street Number
and Name
12.b. Apt.

Ste.

Flr.

12.c. City or Town
12.d. State

1.d. I (choose one)
am not
am
subject to any order of any court or administrative agency
disbarring, suspending, enjoining, restraining, or otherwise
restricting me in the practice of law. If you are subject to
any orders, explain in the space below. (If you need
additional space, use Part 6.)

2.a.

I am an accredited representative of the following
qualified nonprofit religious, charitable, social
service, or similar organization established in the
United States, so recognized by the Department of
Justice, Board of Immigration Appeals, in accordance
with 8 CFR 292.2. Provide the name of the
organization and the expiration date of accreditation.

2.b. Name of Recognized Organization

12.e. ZIP Code

12.f. Province

2.c. Date accreditation expires
(mm/dd/yyyy) ►

12.g. Postal Code
12.h. Country

Form G-28 02/25/15 N

Page 2 of 4

If you do not want to receive original notices or secure
identity documents directly, but would rather have such
notices and documents sent to your attorney of record or
accredited representative, please select all applicable
boxes below:

Part 3. Eligibility Information for Attorney or
Accredited Representative (continued)
3.

I am associated with
,
the attorney or accredited representative of record
who previously filed Form G-28 in this case, and my
appearance as an attorney or accredited representative
is at his or her request.

I request DHS send any notice (including Form I-94)
on an application, petition, or request to the business
address of my attorney of record or accredited
representative as listed in this form. I understand that
I may change this election at any future date through
written notice to DHS.

DRAFT
NOT
FOR
PRODUCTION
02/25/2015

NOTE: If you select this item, also complete Item
Numbers 1.a. - 1.b. or Item Numbers 2.a. - 2.c. in
Part 3. (whichever is appropriate).
4.a.

2.a

2.b.

I am a law student or law graduate working under the
direct supervision of the attorney or accredited
representative of record on this form in accordance
with the requirements in 8 CFR 292.1(a)(2)(iv).

4.b. Name of Law Student or Law Graduate

Part 4. Applicant, Petitioner, Requestor, or
Respondent Consent to Representation, Contact
Information, and Signature

I request that DHS send any secure identity
document, such as a Permanent Resident Card,
Employment Authorization Document, or Travel
Document, that I am approved to receive and
authorized to possess, to the business address of my
attorney of record or accredited representative as
listed in this form. I consent to having my secure
identity document sent to my attorney of record or
accredited representative and understand that I may
request, at any future date and through written notice
to DHS, that DHS send any secure identity document
to me directly.

3.a. Signature of Applicant, Petitioner, Requestor, or
Respondent

Consent to Representation and Release of Information
1.

I have requested the representation of and consented to
being represented by the attorney or accredited
representative named in Part 1. of this form. According
to the Privacy Act of 1974 and DHS policy, I also consent
to the disclosure to the named attorney or accredited
representative of any record pertaining to me that appears
in any system of records of USCIS, ICE or CBP.

When you (the applicant, petitioner, requestor, or
respondent) are represented, DHS will send notices to both
you and your attorney or accredited representative either
through mail or electronic delivery.
DHS will also send the Form I-94, Arrival Departure
Record, to you unless you select Item Number 2.a. in
Part 4. All secure identity documents and Travel
Documents will be sent to you (the applicant, petitioner,
requestor, or respondent) unless you ask us to send those
documents to your attorney of record or accredited
representative.

Form G-28 02/25/15 N

3.b. Date of Signature (mm/dd/yyyy)►

Part 5. Signature of Attorney or Accredited
Representative

I have read and understand the regulations and conditions
contained in 8 CFR 103.2 and 292 governing appearances and
representation before the Department of Homeland Security.
I declare under penalty of perjury under the laws of the United
States that the information I have provided on this form is true
and correct.
1.

Signature of Attorney or Accredited Representative

2.

Signature of Law Student or Law Graduate

3.

Date of Signature (mm/dd/yyyy)►

Page 3 of 4

Part 6. Additional Information
Use the space below to provide additional information
pertaining to Part 3., Item Numbers 1.a. - 1.d.

DRAFT
NOT
FOR
PRODUCTION
02/25/2015
Form G-28 02/25/15 N

Page 4 of 4