Form I-765 TOC

TABLE OF CHANGES – FORM

FORM I-765, Application for Employment Authorization

OMB No 1615-0040

02/13/2015

LOCATION	CURRENT VERSION	PROPOSED CHANGES
Page 1	1. Name (Family Name in CAPS) (First) (Middle) 3. U.S. Mailing Address (Street Number and Name) (Apt. Number) (Town or City) (State/Country) (ZIP Code) 4. Country of Citizenship/Nationality 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.). 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-Verify, and your employer's E- Verify Company Identification Number or a valid E-Verify Client Company Identification Number in the space below. 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 Address Signature Date	1. Full Name (Family Name) (First Name) (Middle Name) 3. U.S. Mailing Address (Street Number and Name) (Apt. Number) (Town or City) (State) (ZIP Code) 4. Country of Citizenship or Nationality 16. Eligibility Category. 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.). 17. (c)(3)(C) Eligibility Category. If you entered the eligibility category, (c)(3)(C), in Question 16 above, list your degree, your employer's name as listed in E-Verify, and your employer's E- Verify Company Identification Number or a valid E-Verify Client Company Identification Number in the space below. 18. (c)(26) Eligibility Category. If you entered the eligibility category, (c)(26), in Question 16 above, please provide the receipt number of your H-1B principal spouse’s most recent Form I-797 Notice of Approval for Form I-129 Applicant’s Signature I certify, under penalty of perjury, 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 Date of Signature (mm/dd/yyyy) Telephone Number Signature of Person Preparing Form, If Other Than Applicant. 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. Signature Date of Signature (mm/dd/yyyy) Printed Name Address

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