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8. Marital Status
Single/Married/Divorced/Widowed
9. 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)
No (Proceed to Question 12.)
12. Date of Last Entry Into the
U.S., on or about (mm/dd/yyyy)
13. Place of Last Entry into the
U.S.
14. Status at Last Entry (B-2
Visitor, F-1 Student, No Lawful Status, etc.)
15. Current Immigration Status
(Visitor, Student, etc.)
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.
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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.
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 these Instructions for information about providing
court dispositions.
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.
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9.a. Has
the Social Security Administration (SSA) ever officially issued a
Social Security card to you? Yes/No
NOTE:
If you answered “Yes” to Item
Number 9.a., provide the
information requested in Item
Number 9.b.
9.b.
Provide your Social Security number
(SSN) (if known)
10.
Do you want the SSA to issue you a Social Security card? (You
must also answer “Yes” to Item
Number 11., Consent
for Disclosure, to receive a
card.) Yes/No
NOTE: If
you answered “No” to Item
Number 10., skip to Item
Number 14. If you answered “Yes”
to Item Number 10.,
you must also answer “Yes” to Item
Number 11.
11.
Consent for Disclosure:
I authorize disclosure of information from this application to
the SSA as required for the purpose of assigning me an SSN and
issuing me a Social Security card. Yes/No
NOTE: If
you answered “Yes” to Item
Numbers 10. -
11.,
provide the information requested
in Item Numbers 12.a. -
13.b.
Father’s
Name
12.a.
Family Name (Last Name)
12.b.
Given Name (First Name)
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Mother’s
Name (Provide your mother’s
birth name.)
13.a.
Family Name (Last Name)
13.b.
Given Name (First Name)
14. Alien
Registration Number (A-Number) or Form I-94 Number (if
any)
15. 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)
No (Proceed to Item Number 16.)
16. Date
of Last Entry Into the U.S., on or about (mm/dd/yyyy)
17. Place
of Last Entry into the U.S.
18.
Status at Last Entry (B-2 Visitor, F-1 Student, No Lawful
Status, etc.)
19. Current
Immigration Status (Visitor, Student, etc.)
20.
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.
21.
(c)(3)(C) Eligibility
Category.
If you entered the
eligibility category
(c)(3)(C) in
Item Number 20.
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
22.
(c)(26)
Eligibility
Category.
If you entered the
eligibility category
(c)(26) in
Item Number 20.
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.
23.
(c)(35) and (c)(36) Eligibility Category
a. If you entered the
eligibility category (c)(35) or (c)(36) in Item Number 20.
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 Number 23.b.,
refer to Item Number 5., Item H. or Item I. in
the Who May File Form I-765 section of these Instructions
for information about providing court dispositions.
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
Item Number 20.
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