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

Application for Permission to Reapply for Admission
Into the United States After Deportation or Removal
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-212
OMB No. 1615-0018
Expires 12/31/2013

For DHS Use Only
Alien Registration Number

Fee Stamp

Action Block

A-

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Initial Receipt

Transferred In

Approved

Relocated Returned

Remarks

INA 212(a)(9)(A) for Advance
Approval
INA 212(a)(9)(A)

DHS Office Name/Location

Transferred Out

INA 212(a)(9)(C)

Denied

► Start Here. Type or print in black ink.

Part 1. Information About You

Mailing Address

1.

NOTE: If you are outside the United States, provide a U.S.
mailing address, if available. If a U.S. mailing address is not
available, provide your mailing address abroad.

Alien Registration Number (A-Number) (if any)
► A-

Your Full Name

4.a. In Care Of Name

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

4.b. Street Number
and Name

4.c.

Apt.

Ste.

Flr.

2.c. Middle Name

4.d. City or Town

Other Names Used

List all other names you have ever used, including maiden
names, aliases, and nicknames. If you need extra space to
complete this section, use the space provided in Part 8.
Additional Information.
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name

4.e. State

4.f.

ZIP Code

4.g. Province
4.h. Postal Code
4.i.

Country

5.

Is your mailing address the same address where you
currently live (physical address)?
Yes

No

If you answered "No" to Item Number 5., provide your
current physical address in Item Numbers 6.a. - 6.h.

Form I-212 03/12/14 N

Page 1 of 8

Part 1. Information About You (continued)
Physical Address

15.a. USCIS Receipt Number (if any)

6.a. Street Number
and Name
6.b.

Apt.

If you are seeking consent to reapply in connection with your
application to adjust your status to that of a lawful permanent
resident, provide information in Item Numbers 15.a. - 15.c.

Ste.

Flr.

15.b. Where did you file your application (for example,
"USCIS Office Name" or "Lockbox")?

6.c. City or Town

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6.d. State
6.f.

6.e. ZIP Code

Province

15.c. Date Filed (mm/dd/yyyy)
16.

Are you submitting Form I-601, Application for Waiver
of Grounds of Inadmissibility, along with this application?

6.g. Postal Code

Yes

6.h. Country

If you answered "No," provide the information requested below
about previously filed Forms I-601 (if any):

Other Information About You
7.

U.S. Social Security Number (if any)
►

8.

Gender

9.

Date of Birth (mm/dd/yyyy)

10.

City or Town of Birth

11.

State or Province of Birth (if applicable)

12.

Country of Birth

13.

No

Male

17.b. Where did you file your application (for example,
"USCIS Office Name" or "Lockbox")?

Female

Country of Citizenship or Nationality

If you seek an immigrant or nonimmigrant visa and you are
or will file your application for consent to reapply with your
immigrant or nonimmigrant visa application, provide the
information requested in Item Numbers 14.a. - 14.b.
14.a. The Department of State (DOS) Consular Case Number
(if available)

14.b. The location of the U.S. Embassy or U.S. Consulate where
your immigrant visa application is being or will be made
City

17.a. USCIS Receipt Number for Form I-601 (if any)

17.c. Date Filed (mm/dd/yyyy)

Part 2. Reasons You Are Filing Form I-212

If you are inadmissible to the United States for the following
reason, select "Yes" and then select the appropriate boxes. If
you need extra space to complete this section, use the space
provided in Part 8. Additional Information.

Removal as an Arriving Alien (INA section
212(a)(9)(A)(i))

1.a. 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.
Yes
No
1.b.

I have only been removed once, and my last removal
was less than five years ago.

1.c.

I have been removed at least two or more times, and
my last removal was less than 20 years ago.

1.d.

I have been convicted of an aggravated felony in the
United States or abroad, before or after my removal
from the United States. Provide information on your
aggravated felony convictions in Part 8. Additional
Information and include the required evidence.

Country

Form I-212 03/12/14 N

Page 2 of 8

Periods of Unlawful Presence

Part 2. Reasons You Are Filing Form I-212
(continued)

5.b. From (mm/dd/yyyy)

2.a. Date you were removed from the United States
(mm/dd/yyyy)

5.c. To (mm/dd/yyyy)
6.a. Date you departed the United States after your period of
unlawful presence (mm/dd/yyyy)

2.b. Location from where you were removed
City or Town

6.b. Location where you departed the United States after your
period of unlawful presence
City or Town

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State

State

Removal as a Deportable Alien (INA section
212(a)(9)(A)(ii))

3.a. 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 of removal
was outstanding.
Yes
No
3.b.
3.c.
3.d.

6.c. Location where you reentered or attempted to reenter the
United States
City or Town

I have only been removed once and my removal was
less than 10 years ago.
I have been removed at least two or more times, and
my last removal was less than 20 years ago.

I have been convicted of an aggravated felony in the
United States or abroad, before or after my removal
from the United States. Provide information on your
aggravated felony convictions in Part 8. Additional
Information and include the required evidence.

4.a. Date you were excluded, deported, or removed from the
United States (mm/dd/yyyy)
4.b. Location from where you were removed
City or Town

6.d. Date you attempted to unlawfully enter or reenter the
United States after period of unlawful presence
(mm/dd/yyyy)

Entry After Removal (INA section
212(a)(9)(C)(i)(II))

7.a

I entered or attempted to enter the United States without
being admitted or paroled after having been excluded,
deported, or removed.
Yes
No
NOTE: If you answered “Yes” to Item Number 7.a.,
list all the dates when you were excluded, deported, or
removed from the United States. If you need extra space
to complete this section, use the space provided in Part 8.
Additional Information.

State

Entry After Unlawful Presence in the Aggregate of
1 Year (INA section 212(a)(9)(C)(i)(I))
5.a. I entered or attempted to enter the United States without
being admitted or paroled, after having been unlawfully
present in the United States on or after April 1, 1997, for
a period of more than one year, in the aggregate.
Yes

No

NOTE: If you answered "Yes" to Item Number 5.a., list
all the time periods during which you were unlawfully
present in the United States (including any periods in
which you overstayed your lawful status). Begin with
your most recent period of unlawful presence. Also attach
evidence demonstrating that you have remained outside
the United States for 10 years since your last departure.
Form I-212 03/12/14 N

State

7.b. Date you were excluded, deported, or removed from the
United States (mm/dd/yyyy)
8.a. Location where you reentered or attempted to reenter the
United States after your exclusion, deportation, or removal
City or Town

State

8.b. Date you entered or attempted to reenter the United States
after exclusion, deportation, or removal (mm/dd/yyyy)

Page 3 of 8

Part 3. Reasons For Your Request For
Permission to Reapply

5.

If the Department of Homeland Security (DHS) permits you to
reenter the United States, what immigration status will you seek?
1.a.

Permanent Resident

1.b.

Visitor

1.c.
1.d.

2.

6.

Brown

Green

Maroon

Pink

Hazel
Unknown/Other

Hair Color (Select only one box)

Other (Explain)

Explain why you would like to reenter the United States

NOTE: If you need extra space to complete this section, use
the space provided in Part 8. Additional Information.
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)

Black
Gray
White

Blond
Red

Unknown/
Other

Part 5. Applicant's Statement, Contact
Information, Acknowledgement of Appointment
at USCIS Application Support Center,
Certification, and Signature

NOTE: Read the information on penalties in the Penalties
section of the Form I-212 Instructions before completing this
part.

Applicant's Statement

NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
1.a.

I can read and understand English, and have read and
understand every question and instruction on this
application, as well as my answer to every question.
I have read and understand the Acknowledgement of
Appointment at USCIS Application Support
Center.

1.b.

The interpreter named in Part 6. has read to me every
question and instruction on this application, as well as
my answer to every question, in

3.c. Middle Name
3.d. Relationship

My relative is (Select one):
A lawful permanent resident.
4.a.
A U.S. citizen.

Ethnicity (Select only one box)
Hispanic or Latino
Not Hispanic or Latino
Race (Select all applicable boxes)
White
Asian
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander

3.

Height

Feet

4.

Weight

Pounds

Form I-212 03/12/14 N

Inches

,

a language in which I am fluent. I understand every
question and instruction on this application as
translated to me by my interpreter, and have provided
complete, true, and correct responses in the language
indicated above. The interpreter named in Part 6. has
also read the Acknowledgement of Appointment at
USCIS Application Support Center to me, in the
language in which I am fluent, and I understand this
Application Support Center (ASC) Acknowledgement
as read to me by my interpreter.

Part 4. Biographic Information

2.

Blue

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Student

U.S. Citizen or Lawful Permanent Resident Family
Members (if any)

1.

Black
Gray

Bald (No hair)
Brown
Sandy

NOTE: If you need extra space to complete this section, use
the space provided in Part 8. Additional Information.

4.b.

Eye Color (Select only one box)

2.

I have requested the services of and consented to
,
who
is
is not an attorney or accredited
representative, preparing this application for me. This
person who assisted me in preparing my application
has reviewed the Acknowledgement of Appointment
at USCIS Application Support Center with me, and
I understand the ASC Acknowledgement.

Page 4 of 8

I furthermore authorize release of information contained in this
application, in supporting documents, and in my USCIS records
to other entities and persons where necessary for the
administration and enforcement of U.S. immigration laws.

Part 5. Applicant's Statement, Contact
Information, Acknowledgement of Appointment
at USCIS Application Support Center,
Certification, and Signature (continued)

I certify, under penalty of perjury, that the information in my
application and any document submitted with my application
were provided by me and are complete, true, and correct.

Applicant's Contact Information
3.

Applicant's Daytime Telephone Number

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Applicant's Signature

4.

Applicant's Mobile Telephone Number (if any)

6.a. Applicant's Signature

5.

Applicant's Email Address (if any)

6.b. Date of Signature (mm/dd/yyyy)

NOTE TO ALL APPLICANTS: If you do not completely fill
out this application or fail to submit required documents listed
in the instructions, USCIS may deny your application.

Acknowledgement of Appointment at USCIS
Application Support Center
I,

,

understand that the purpose of a USCIS ASC appointment is
for me to provide fingerprints, photograph, and/or signature
and to re-affirm that all of the information in my application is
complete, true, and correct and was provided by me. I
understand that I will sign my name to the following
declaration which USCIS will display to me at the time I
provide my fingerprints, photograph, and/or signature during
my ASC appointment.

By signing here, I declare under penalty of perjury that I
have reviewed and understand my application, petition, or
request as identified by the receipt number displayed on the
screen above, and all supporting documents, applications,
petitions, or requests filed with my application, petition, or
request that I (or my attorney or accredited representative)
filed with USCIS, and that all of the information in these
materials is complete, true, and correct.

Part 6. Interpreter's Contact Information,
Certification, and Signature

Provide the following information concerning the interpreter.

Interpreter's Full Name

1.a. Interpreter's Family Name (Last Name)

1.b. Interpreter's Given Name (First Name)

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address

I also understand that when I sign my name, provide my
fingerprints, and am photographed at the USCIS ASC, I will be
re-affirming that I willingly submit this application; I have
reviewed the contents of this application; all of the information in
my application and all supporting documents submitted with my
application were provided by me and are complete, true, and
correct; and if I was assisted in completing this application, the
person assisting me also reviewed this Acknowledgement of
Appointment at USCIS Application Support Center with me.

3.a. Street Number
and Name

Applicant's Certification

3.g. Postal Code

Copies of documents I have submitted are exact photocopies of
unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date.
Furthermore, I authorize the release of any information from any
and all of my records that USCIS may need to determine my
eligibility for the immigration benefit that I seek.

3.h. Country

Form I-212 03/12/14 N

3.b.

Apt.

Ste.

Flr.

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

3.e. ZIP Code

Province

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Part 6. Interpreter's Contact Information,
Certification, and Signature (continued)
Interpreter's Contact Information

Part 7. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Application, If Other Than the
Applicant

4.

Interpreter's Daytime Telephone Number

Provide the following information concerning the preparer.

5.

Interpreter's Email Address (if any)

Preparer's Full Name

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1.a. Preparer's Family Name (Last Name)

Interpreter's Certification

1.b. Preparer's Given Name (First Name)

I certify that:

I am fluent in English and
,
which is the same language provided in Part 5., Item Number
1.b.;
I have read to this applicant every question and instruction on
this application, as well as the answer to every question, in the
language provided in Part 5., Item Number 1.b.; and

I have read the Acknowledgement of Appointment at USCIS
Application Support Center to the applicant in the same
language provided in Part 5., Item Number 1.b.

The applicant has informed me that he or she understands every
instruction and question on the application, as well as the answer
to every question, and the applicant verified the accuracy of
every answer; and
The applicant has also informed me that he or she understands the
ASC Acknowledgement and that by appearing for a USCIS ASC
biometric services appointment and providing his or her
fingerprints, photograph, and/or signature, he or she is
re-affirming that the contents of this application and all
supporting documentation are complete, true, and correct.

Interpreter's Signature
6.a. Interpreter's Signature

6.b. Date of Signature (mm/dd/yyyy)

Form I-212 03/12/14 N

2.

Preparer's Business or Organization Name (if any)

Preparer's Mailing Address

3.a. Street Number
and Name

3.b.

Apt.

Ste.

Flr.

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

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Preparer's Contact Information

4.

Preparer's Daytime Telephone Number

5.

Preparer's Fax Number

6.

Preparer's Email Address (if any)

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Part 7. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Application, If Other Than the
Applicant (continued)
Preparer's Statement
7.a.

7.b.

I am not an attorney or accredited representative
but have prepared this application on behalf of
the applicant and with the applicant's consent.

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I am an attorney or accredited representative and
my representation of the applicant in this case
extends
does not extend beyond the
preparation of this application.
NOTE: If you are an attorney or accredited
representative whose representation extends
beyond preparation of this application you must
submit a completed Form G-28, Notice of
Entry of Appearance as Attorney or Accredited
Representative, or G-28I, Notice of Entry of
Appearance as Attorney In Matters Outside the
Geographical Confines of the United States,
with this application.

Preparer's Certification

By my signature, I certify, swear, or affirm, under penalty of
perjury, that I prepared this application on behalf of, at the request
of, and with the express consent of the applicant. I completed this
application based only on responses the applicant provided to me.
After completing the application, I reviewed it and all of the
applicant's responses with the applicant, who agreed with every
answer on the application. If the applicant supplied additional
information concerning a question on the application, I recorded it
on the application. I have also read the Acknowledgement of
Appointment at USCIS Application Support Center to the
applicant and the applicant has informed me that he or she
understands the ASC Acknowledgement.

Preparer's Signature
8.a. Preparer's Signature

8.b. Date of Signature (mm/dd/yyyy)

Form I-212 03/12/14 N

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5.a. Page Number

Part 8. Additional Information
If you need extra space to provide any additional information
within this application, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this application or attach a separate
sheet of paper. Include your name and A-Number (if any) at the
top of each sheet; indicate the Page Number, Part Number,
and Item Number to which your answer refers; and sign and
date each sheet.

5.b. Part Number

5.c. Item Number

5.d.

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

1.c. Middle Name
2.

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

A-Number (if any) ► A-

6.d.

3.a. Page Number

3.d.

3.b. Part Number

3.c. Item Number

7.a. Page Number

7.d.

4.a. Page Number

4.b. Part Number

4.c. Item Number

4.d.

8.a. Applicant's Signature

8.b. Date of Signature (mm/dd/yyyy)

Form I-212 03/12/14 N

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