I-765 Application for Employment Authorization Document

USCIS
Form I-765

Application For Employment Authorization
Department of Homeland Security
U.S. Citizenship and Immigration Services
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OMB No. 1615-0040
Expires 02/28/2018

Initial Receipt

Resubmitted

Relocated

DRAFT
NOT FOR
PRODUCTION
01/19/2017
Received

Sent

Completed

Approved

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:

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

Denied

A#

Applicant is filing under section 274a.12

► START HERE - Type or print in black ink.

9.a. Has the Social Security Administration (SSA) ever
officially issued a Social Security card to you?
Yes

I am applying for:

Permission to accept employment.

No

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

First Name

Middle Name

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.)

Other Names Used (include Maiden Name)
Family Name

3.

9.b. Provide your Social Security number (SSN) (if known)
►

Family Name

2.

NOTE: If you answered “Yes” to Item Number 9.a.,
provide the information requested in Item Number 9.b.

First Name

Middle Name

U.S. Mailing Address
Apt. Number

Town or City

State

ZIP Code

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.

Street Number and Name

Yes

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.
4.

Country of Citizenship or Nationality
Father's Name

5.

Place of Birth
Town or City

State/Province

6.

Date of Birth (mm/dd/yyyy)

7.

Gender

8.

Marital Status
Single

Male

Married

Form I-765 01/17/17 N

Country

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

Female

Divorced

Widowed
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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.

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)

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.

DRAFT
NOT FOR
PRODUCTION
01/19/2017

15. Have you ever before applied for employment
authorization from USCIS?
Yes (Complete the following questions.)
Which USCIS Office?

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

Dates

Results (Granted or Denied - attach all documentation)

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.

No (Proceed to Item Number 16.)

Certification

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.)

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

19. Current Immigration Status (Visitor, Student, etc.)

Date of Signature (mm/dd/yyyy)

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

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

Employer's E-Verify Company Identification Number or a
Valid E-Verify Client Company Identification Number

Form I-765 01/17/17 N

Address

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