Form I-765 Application for Employment Authorization Document

Application For Employment Authorization

USCIS
Form I-765

Department of Homeland Security
U.S. Citizenship and Immigration Services
Authorization/Extension
Valid From

For
USCIS
Use
Only

Fee Stamp

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

Action Block

Authorization/Extension
Valid Through

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Alien Registration Number
Remarks

A-

To be completed by an attorney or
Board of Immigration Appeals (BIA)accredited representative (if any).

Select this box if Form G-28
is attached.

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

Part 1. Reason for Applying

Other Names Used

I am applying for (select only one box):

Provide all other names you have ever used, including aliases,
maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 6.
Additional Information.

1.a.

Initial permission to accept employment.

1.b.

Replacement of lost, stolen, or damaged employment
authorization document, or correction of my
employment authorization document NOT DUE to
U.S. Citizenship and Immigration Services (USCIS)
error.

1.c.

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

NOTE: Replacement (correction) of an employment
authorization document due to USCIS error does not
require a new Form I-765 and filing fee. Refer to
Replacement for Card Error in the What is the
Filing Fee section of the Form I-765 Instructions for
further details.

2.c. Middle Name

Renewal of my permission to accept employment.
(Attach a copy of your previous employment
authorization document.)

3.c. Middle Name

Part 2. Information About You
Your Full Legal Name

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

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

4.c. Middle Name

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name

Form I-765 07/17/17 N

Page 1 of 7

Part 2. Information About You (continued)

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

Your U.S. Mailing Address

14.

5.a. In Care Of Name (if any)

Do you want the SSA to issue you a Social Security card?
(You must also answer “Yes” to Item Number 15.,
Consent for Disclosure, to receive a card.)
Yes

5.b. Street Number
and Name
5.c.

Apt.

Ste.

5.d. City or Town

NOTE: If you answered “No” to Item Number 14., skip
to Part 2., Item Number 18.a. If you answered “Yes” to
Item Number 14., you must also answer “Yes” to Item
Number 15.

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15.

5.e. State

5.f.

ZIP Code

(USPS ZIP Code Lookup)

6.

Is your current mailing address the same as your physical
address?
Yes
No
NOTE: If you answered “No” to Item Number 6.,
provide your physical address below.

7.b.

Apt.

Ste.

Provide your father's birth name.

9.

Flr.

Provide your mother's birth name.
17.a. Family Name
(Last Name)
17.b. Given Name
(First Name)

Alien Registration Number (A-Number) (if any)
► A-

Your Country or Countries of Citizenship or
Nationality

USCIS Online Account Number (if any)
►

10.

Gender

11.

Marital Status
Single

12.

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

7.e. ZIP Code

Other Information
8.

NOTE: If you answered “Yes” to Item Numbers
14. - 15., provide the information requested in Item
Numbers 16.a. - 17.b.

Mother's Name

7.c. City or Town
7.d. State

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

Father's Name

U.S. Physical Address
7.a. Street Number
and Name

No

Male

Female

List all countries where you are currently a citizen or national.
If you need extra space to complete this item, use the space
provided in Part 6. Additional Information.
18.a. Country

Married

Divorced

Widowed

18.b. Country

Have you previously filed Form I-765?

Yes

No

13.a. Has the Social Security Administration (SSA) ever
officially issued a Social Security card to you?
Yes
No
NOTE: If you answered “No” to Item Number 13.a.,
skip to Item Number 14. If you answered “Yes” to Item
Number 13.a., provide the information requested in Item
Number 13.b.
Form I-765 07/17/17 N

Page 2 of 7

Part 2. Information About You (continued)

Information About Your Eligibility Category
27.

Place of Birth
List the city/town/village, state/province, and country where
you were born.
19.a. City/Town/Village of Birth

20.

(
28.

Date of Birth (mm/dd/yyyy)

21.a. Form I-94 Arrival-Departure Record Number (if any)
►

)

28.b. Employer's Name as Listed in E-Verify

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

29.

21.b. Passport Number of Your Most Recently Issued Passport

30.

21.d. Country That Issued Your Passport or Travel Document
21.e. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
22.

Date of Your Last Arrival Into the United States, On or
About (mm/dd/yyyy)

23.

Place of Your Last Arrival Into the United States

24.

Immigration Status at Your Last Arrival (for example,
B-2 visitor, F-1 student, or no status)

25.

Your Current Immigration Status or Category (for example,
B-2 visitor, F-1 student, parolee, deferred action, or no
status or category)
Student and Exchange Visitor Information System
(SEVIS) Number (if any)
► N-

(c)(26) Eligibility Category. If you entered the eligibility
category (c)(26) in Item Number 27., provide the receipt
number of your H-1B spouse's most recent Form I-797
Notice for Form I-129, Petition for a Nonimmigrant
Worker.
►

21.c. Travel Document Number (if any)

Form I-765 07/17/17 N

)(

28.a. Degree

Information About Your Last Arrival in the
United States

26.

)(

(c)(3)(C) STEM OPT Eligibility Category. If you
entered the eligibility category (c)(3)(C) in Item Number
27., provide the information requested in Item Numbers
28.a - 28.c.

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19.b. State/Province of Birth
19.c. Country of Birth

Eligibility Category. Refer to the Who May File Form
I-765 section of the Form I-765 Instructions to determine
the appropriate eligibility category for this application.
Enter the appropriate letter and number for your eligibility
category below (for example, (a)(8), (c)(17)(iii)).

(c)(8) Eligibility Category. If you entered the eligibility
category (c)(8) in Item Number 27., have you EVER
been arrested for and/or convicted of any crime?
Yes

No

NOTE: If you answered “Yes” to Item Number 30.,
refer to Special Filing Instructions for Those With
Pending Asylum Applications (c)(8) in the Required
Documentation section of the Form I-765 Instructions
for information about providing court dispositions.

31.a. (c)(35) and (c)(36) Eligibility Category. If you entered
the eligibility category (c)(35) in Item Number 27., please
provide the receipt number of your Form I-797 Notice for
Form I-140, Immigrant Petition for Alien Worker. If you
entered the eligibility category (c)(36) in Item Number
27., please provide the receipt number of your spouse's or
parent's Form I-797 Notice for Form I-140.
►

31.b. If you entered the eligibility category (c)(35) or (c)(36) in
Item Number 27., have you EVER been arrested for
and/or convicted of any crime?
Yes
No
NOTE: If you answered “Yes” to Item Number 31.b.,
refer to Employment-Based Nonimmigrant Categories,
Items 8. - 9., in the Who May File Form I-765 section
of the Form I-765 Instructions for information about
providing court dispositions.
Page 3 of 7

Applicant's Declaration and Certification

Part 3. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature

Copies of any documents I have submitted are exact photocopies
of unaltered, original documents, and I understand that USCIS
may require that I submit original documents to USCIS at a later
date. Furthermore, I authorize the release of any information
from any and all of my records that USCIS may need to
determine my eligibility for the immigration benefit that I seek.

NOTE: Read the Penalties section of the Form I-765
Instructions before completing this section. You must file
Form I-765 while in the United States.

I furthermore authorize release of information contained in this
application, in supporting documents, and in my USCIS
records, to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.

Applicant's Statement

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NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
1.a.

I can read and understand English, and I have read
and understand every question and instruction on this
application and my answer to every question.

1.b.

The interpreter named in Part 4. read to me every
question and instruction on this application and my
answer to every question in
a language in which I am fluent, and I understood
everything.

2.

1) I reviewed and understood all of the information
contained in, and submitted with, my application; and

,

Applicant's Contact Information
3.

Applicant's Daytime Telephone Number

4.

Applicant's Mobile Telephone Number (if any)

5.

Applicant's Email Address (if any)

6.

2) All of this information was complete, true, and correct
at the time of filing.

,

At my request, the preparer named in Part 5.,

prepared this application for me based only upon
information I provided or authorized.

I understand that USCIS may require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, if I am required to provide
biometrics, I will be required to sign an oath reaffirming that:

Select this box if you are a Salvadoran or Guatemalan
national eligible for benefits under the ABC
settlement agreement.

I certify, under penalty of perjury, that all of the information in
my application and any document submitted with it were
provided or authorized by me, that I reviewed and understand
all of the information contained in, and submitted with, my
application and that all of this information is complete, true, and
correct.

Applicant's Signature

7.a. Applicant's Signature

7.b. Date of Signature (mm/dd/yyyy)

NOTE TO ALL APPLICANTS: If you do not completely fill
out this application or fail to submit required documents listed
in the Instructions, USCIS may deny your application.

Part 4. Interpreter's Contact Information,
Certification, and Signature

Provide the following information about the interpreter.

Interpreter's Full Name
1.a. Interpreter's Family Name (Last Name)
1.b. Interpreter's Given Name (First Name)
2.

Form I-765 07/17/17 N

Interpreter's Business or Organization Name (if any)

Page 4 of 7

Part 4. Interpreter's Contact Information,
Certification, and Signature

Part 5. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, If Other Than the Applicant

Interpreter's Mailing Address

Provide the following information about the preparer.

3.a. Street Number
and Name

Preparer's Full Name

3.b.

Apt.

Ste.

3.c. City or Town
3.d. State
3.f.

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3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

1.a. Preparer's Family Name (Last Name)

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Mobile Telephone Number (if any)

1.b. Preparer's Given Name (First Name)

2.

Preparer's Mailing Address

3.a. Street Number
and Name
3.b.

Interpreter's Email Address (if any)

Apt.

Ste.

Flr.

3.c. City or Town
3.d. State
3.f.

6.

Preparer's Business or Organization Name (if any)

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Interpreter's Certification

I certify, under penalty of perjury, that:

I am fluent in English and
,
which is the same language specified in Part 3., Item Number
1.b., and I have read to this applicant in the identified language
every question and instruction on this application and his or her
answer to every question. The applicant informed me that he or
she understands every instruction, question, and answer on the
application, including the Applicant's Declaration and
Certification, and has verified the accuracy of every answer.

Preparer's Contact Information

4.

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number (if any)

6.

Preparer's Email Address (if any)

Interpreter's Signature
7.a. Interpreter's Signature

7.b. Date of Signature (mm/dd/yyyy)

Form I-765 07/17/17 N

Page 5 of 7

Part 5. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, If Other Than the Applicant
(continued)
Preparer's Statement
7.a.

I am not an attorney or accredited representative
but have prepared this application on behalf of
the applicant and with the applicant's consent.

7.b.

I am an attorney or accredited representative and
my representation of the applicant in this case
extends
does not extend beyond the
preparation of this application.

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NOTE: If you are an attorney or accredited ay
need to submit a completed Form G-28, Notice
of Entry of Appearance as Attorney or
Accredited Representative, with this application.

Preparer's Certification

By my signature, I certify, under penalty of perjury, that I
prepared this application at the request of the applicant. The
applicant then reviewed this completed application and
informed me that he or she understands all of the information
contained in, and submitted with, his or her application,
including the Applicant's Declaration and Certification, and
that all of this information is complete, true, and correct. I
completed this application based only on information that the
applicant provided to me or authorized me to obtain or use.

Preparer's Signature
8.a. Preparer's Signature

8.b. Date of Signature (mm/dd/yyyy)

Form I-765 07/17/17 N

Page 6 of 7

5.a. Page Number

Part 6. Additional Information
If you need extra space to provide any additional information
within this application, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this application or attach a separate
sheet of paper. Type or print your name and A-Number (if any)
at the top of each sheet; indicate the Page Number, Part
Number, and Item Number to which your answer refers; and
sign and date each sheet.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.

5.b. Part Number

5.c. Item Number

5.d.

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6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

A-Number (if any) ► A-

3.a. Page Number

3.b. Part Number

3.d.

3.c. Item Number

6.d.

7.a. Page Number
7.d.

4.a. Page Number

4.b. Part Number

4.d.

Form I-765 07/17/17 N

4.c. Item Number

Page 7 of 7