I765-frm-toc-ier+ssa-06292017

TABLE OF CHANGES – FORM

Form I-765, Application for Employment Authorization

OMB Number: 1615-0040

06/30/2017

Reason for Revision: Rescinding International Entrepreneur Rule (no edits were made to the form for this initiative)

Legend for Proposed Text:

• Black font = Current text

• Yellow highlights = Text incorporated from SSA version

Current Page Number and Section	Current Text	Proposed Text
Page 1	START HERE - Type or print in black ink. I am applying for: 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). 1. Full Name Family Name First Name Middle Name 2. Other Names Used (include Maiden 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 5. Place of Birth Town or City State/Province Country 6. Date of Birth (mm/dd/yyyy) 7. Gender Male Female 8. Marital Status Single Married Divorced Widowed 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)	START HERE - Type or print in black ink. I am applying for: 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). 1. Full Name Family Name First Name Middle Name 2. Other Names Used (include Maiden 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 5. Place of Birth Town or City State/Province Country 6. Date of Birth (mm/dd/yyyy) 7. Gender Male Female 8. Marital Status Single Married Divorced Widowed 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)
Page 2	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 Your Last Arrival or Entry Into the U.S., On or About (mm/dd/yyyy) 17. Place of Your Last Arrival or 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. ([Fillable field x3]) 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. Applicant's 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. Preparer's Signature Date of Signature (mm/dd/yyyy) Printed Name Address	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 Question 16.) 16. Date of Your Last Arrival or Entry Into the U.S., On or About (mm/dd/yyyy) 17. Place of Your Last Arrival or 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. ([Fillable field x3]) 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. Applicant's 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. Preparer's Signature Date of Signature (mm/dd/yyyy) Printed Name Address

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