Form I-765 Application for Employment Authorization Document

OMB No. 1615-0040; Expires 02/28/2018

I-765, Application For
Employment Authorization

Department of Homeland Security
U.S. Citizenship and Immigration Services
Action Block

Fee Stamp

For
USCIS
Use
Only

Initial Receipt

Resubmitted

Relocated
Received

Sent

Completed

DRAFT
NOT FOR
PRODUCTION
12/09/2016
Application Denied - Failed to establish:

Application Approved

Eligibility under
8 CFR 274a.12
(a) or (c)

Authorization/Extension Valid From
Authorization/Extension Valid To
Subject to the following conditions:

I am applying for:
1.

Denied

A-Number

Applicant is filing under section 274a.12

Permission to accept employment.
Replacement (of lost employment authorization document).
Renewal of my permission to accept employment (attach a copy of your previous employment authorization document).
15. Current Immigration Status (Visitor, Student, etc.)

Full Name
(Family Name)

(First Name)

2.

Other Names Used (include Maiden Name)

3.

U.S. Mailing Address
(Street Number and Name)

(Middle Name)

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.

(Apt. Number)

(Town or City)

(State)

4.

Country of Citizenship or Nationality

5.

Place of Birth
(Town or City)

(ZIP Code)

(State/Province)

6.

Date of Birth (mm/dd/yyyy)

7.

Gender

8.

Marital Status
Married

9.

Economic necessity under
8 CFR 274a.12(c)(14), (18)
and 8 CFR 214.2(f)

Approved

Male

(Country)

Divorced

) (

) (

)

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.
Degree
Employer's Name as listed in E-Verify
Employer's E-Verify Company Identification Number or a Valid
E-Verify Client Company Identification Number

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.

Female

Single

(

Widowed

Social Security Number (Include all numbers you have ever
used, if any)

10. Alien Registration Number (A-Number) or Form I-94 Number
(if any)
11. Have you ever before applied for employment authorization
from USCIS?
Yes (Complete the following questions.)
Which USCIS Office?
Dates
Results (Granted or Denied - attach all documentation)

19. (c)(35) and (c)(36) Eligibility Category
a. If you entered the eligibility category (c)(35) or (c)(36) in
Question 16 above, please provide the receipt number of the
Form I-140 beneficiary's Form I-797 Notice of Approval for
Form I-140.
b.

Have you EVER been arrested for and/or convicted of any
crime?
Yes
No

NOTE: If you answered "Yes" to Item Numbers 19.b., refer to
Item Number 5., Item H. or Item I. in the Who May File Form
I-765 section of the Instructions for information about providing
court dispositions.

No (Proceed to Question 12.)
12. Date of Your Last Arrival or Entry Into the U.S., On or About
(mm/dd/yyyy)
13. Place of Your Last Arrival or Entry into the U.S.
14. Status at Last Entry (B-2 Visitor, F-1 Student, No Lawful
Status, etc.)
Form I-765 11/04/15 Y

Certification
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.
Applicant's Signature
Date of Signature (mm/dd/yyyy)

DRAFT
NOT FOR
PRODUCTION
12/09/2016

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.
Preparer's Signature

Date of Signature (mm/dd/yyyy)
Printed Name
Address