Form I-910 Application for Civil Surgeon Designation

USCIS
Form I-910

Application for Civil Surgeon Designation
Department of Homeland Security
U.S. Citizenship and Immigration Services

For
USCIS
Use
Only

Initial Receipt

Received
Sent

OMB No. 1615-0114
Expires 05/31/2018

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Resubmitted

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Remarks

CSID Number

To be completed by an
attorney or accredited
representative (if any).

Select this box if Form
G-28 is attached to
represent the applicant.

Attorney State Bar
Number (if applicable)

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

► START HERE - Type or print in black ink.

Part 1. Information About You (The Applicant)

3.b. Date of Voluntary Termination (mm/dd/yyyy)

1.a. Have you ever been designated as a civil surgeon?
Yes

No

If you answered "Yes" to Item Number 1.a., provide the
following information.
1.b. Period of Designation (mm/dd/yyyy)
From
To

NOTE: If you answered "Yes" to Item Number 2.a. or Item
Number 3.a., above, include a typed or printed explanation of
the circumstances surrounding the revocation or voluntary
termination in Part 9. Additional Information.

Your Full Name

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

1.c. U.S. Citizenship and Immigration Services (USCIS)
Office That Granted the Designation

1.d. Civil Surgeon Identification Number (CSID) (if known)

4.c. Middle Name

Other Names Used
2.a. Has USCIS ever revoked your designation?
Yes

No

If you answered "Yes" to Item Number 2.a., provide the
following information.
2.b. Date of Revocation (mm/dd/yyyy)
3.a. Have you ever voluntarily terminated your designation?
Yes

No

If you answered "Yes" to Item Number 3.a., provide the
following information.

Form I-910 12/23/16 N

List 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 9.
Additional Information.
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c. Middle Name

Other Information
6.

Date of Birth (mm/dd/yyyy)

7.

Gender

Male

Female
Page 1 of 6

Part 1. Information About You (The Applicant)
(continued)
8.

USCIS Online Account Number (if any)
►

9.

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

Additional Office Information
Your application will not be affected if you choose not to provide
the following information. USCIS displays this information on
our website for people who want to find a civil surgeon.
6.

Email Address (For Use By The Public)

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Part 2. Clinical Office Locations

Provide the following information about the locations where
you seek to perform immigration medical examinations. If you
seek to perform immigration medical exams in more than one
location, provide the details for each additional location in the
space provided in Part 9. Additional Information.

Name and Physical Address of the Clinic/Practice
USPS ZIP Code Lookup

7.

Website Address (URL)

8.

Fees for Medical Examination

9.

Acceptable Means of Payment

10.

Accepted Medical Insurance Plans

11.

Languages Spoken

12.

Office Hours

13.

Handicap Accessibility

14.

Other

You must provide the following information. Failure to provide
this information may result in the denial of your application.
See the Additional Office Information section below for more
information about what will be made publicly available.
1.

Name of Clinic/Practice

2.a. Street Number
and Name
2.b.

Apt.

2.c. City or Town
2.d. State

Ste.

Flr.

2.e. ZIP Code

3.

Telephone Number

4.

Fax Number

Part 3. Information About Your Status in the
United States

5.

Email Address (For Use By USCIS)

You must be authorized to work in the United States to be
eligible for civil surgeon designation. Select the box that
accurately states how you are authorized to work in the United
States. (Select only one box.)

NOTE: USCIS will use the contact information listed above
for all civil surgeon-related communication.
UPDATE USCIS OF ANY CHANGES: Civil surgeons are
responsible for notifying USCIS in writing of any updates to the
contact information provided in this application within 15 days
of the change. Visit the USCIS website at www.uscis.gov/I-910
for information on how to submit a change.

Form I-910 12/23/16 N

1.

I am a U.S. citizen or national. (Attach proof that you
are a U.S. citizen or national, such as a copy of a U.S.
passport, birth certificate, or Certificate of
Naturalization.)

2.

I am a Lawful Permanent Resident. (Attach a copy
of your valid Form I-551, Permanent Resident Card.
If you are currently seeking to renew or replace your
Form I-551, attach evidence showing that you are
doing so.)
Page 2 of 6

Part 3. Information About Your Status in the
United States (continued)
3.a.

I am currently present in the United States as a
nonimmigrant. (Attach a copy of your Form I-94
Arrival-Departure Record, a copy of your passport
or travel document, and any documents related to
your nonimmigrant status, such as a copy of the
petition, petition approval, and change or extension
of status application. Also attach a copy of your
valid, unexpired Employment Authorization
Document as proof of your authorization to work in
the United States, if required.)

1.c. Date Issued (mm/dd/yyyy)
1.d. Date Expires (mm/dd/yyyy)

Medical License 2
2.a. State

OR

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3.b. Date of Last Arrival in the U.S. (mm/dd/yyyy)

U.S. Territory

2.b. Medical License Number

2.c. Date Issued (mm/dd/yyyy)

2.d. Date Expires (mm/dd/yyyy)

3.c. Form I-94 Arrival-Departure Record Number (if any)
►
3.d. Passport Number

3.e. Travel Document Number
3.f.

Country of Issuance for Passport or Travel Document

3.g. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)

Part 5. Medical Degrees

You must possess a medical degree as a Doctor of Medicine
(M.D.) or Doctor of Osteopathy (D.O.) to be eligible for civil
surgeon designation. Attach a copy of each medical degree
listed below. If you need extra space to complete this section,
use the space provided in Part 9. Additional Information.

School 1

1.a. School Name

3.h. Current Nonimmigrant Status

4.

I have an Employment Authorization Document
(EAD) granted by USCIS that authorizes me to
work in the United States. (Attach a copy of your
valid, unexpired EAD as proof of your authorization
to work in the United States.)

1.b. Dates of Attendance (mm/dd/yyyy)
From
To

1.c. Degree

School 2
Part 4. Medical Licenses

2.a. School Name

You must be licensed to practice medicine in the state or U.S.
territory in which you seek to perform immigration medical
examinations to be eligible for civil surgeon designation. Attach
a copy of each medical license listed below. If you need extra
space to complete this section, use the space provided in Part 9.
Additional Information.

2.b. Dates of Attendance (mm/dd/yyyy)
From
To
2.c. Degree

Medical License 1
1.a. State

OR

U.S. Territory
1.b. Medical License Number

Form I-910 12/23/16 N

Page 3 of 6

Part 6. Professional Experience
You must establish that you have practiced medicine as a
physician (M.D. or D.O.) for at least four years to be eligible for
designation.
NOTE: In calculating whether you meet the requirement of
four years of practice as a physician, DO NOT count your post
graduate medical training in an internship or residency program.
You can, however, count the time you practiced medicine on
the basis of a post-residency fellowship.

1.b. Dates of Employment (mm/dd/yyyy)

1.c. Street Number
and Name
1.d.

Apt.

Applicant's Statement

NOTE: If applicable, select the box for Item Number 1.
1.

At my request, the preparer named in Part 8.,
,

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

Applicant's Contact Information

1.a. Employer's Name

From

NOTE: Read the Penalties section of the Form I-910
Instructions before completing this section. You must file Form
I-910 while in the United States.

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Submit evidence to establish your professional experience, such
as evaluations, certificates of completion, business tax returns
and business license (for self-employed physicians), or letters of
employment verification. If you need extra space to complete
this section, use the space provided in Part 9. Additional
Information.

Employer 1

Part 7. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature

2.

Applicant's Daytime Telephone Number

3.

Applicant's Mobile Telephone Number (if any)

4.

Applicant's Email Address (if any)

To

Ste.

Flr.

Applicant's Declaration and Certification

1.e. City or Town
1.f.

State

1.g. ZIP Code

1.h. Employer's Daytime Telephone Number

Employer 2

By signing this application, I further agree to comply fully with
the regulations at 8 CFR Part 232. I understand that USCIS
reserves the right to revoke civil surgeon designation in certain
circumstances.

2.a. Employer's Name

2.b. Dates of Employment (mm/dd/yyyy)
From
To
2.c. Street Number
and Name
2.d.

Apt.

Ste.

Flr.

2.e. City or Town
2.f.

State

By signing this application, I accept civil surgeon designation if
my request for designation is granted. Once designated as a
civil surgeon, I agree that I will perform the medical
examinations according to the regulations published by Health
and Human Services (HHS) at 42 CFR Part 34 and the
Technical Instructions for Civil Surgeons by the Centers for
Disease Control and Prevention (CDC).

2.g. ZIP Code

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 designation as a civil surgeon.
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.

2.h. Employer's Daytime Telephone Number

Form I-910 12/23/16 N

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Part 7. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
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.

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number (if any)

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6.

7.

Applicant's Signature

5.a. Applicant's Signature

5.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 8. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Provide the following information about the preparer.

Preparer's Full Name

Preparer's Email Address (if any)

Select this box if the preparer may act as a secondary
point of contact for you. USCIS will contact this
preparer if you cannot be reached using the
information in Part 2.

Preparer's Statement

8.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.

8.b.

I am an attorney or accredited representative and my
representation of the applicant in this case
does not extend beyond the
extends
preparation of this application.
NOTE: If you are an attorney or accredited
representative, you may need to submit a completed
Form G-28, Notice of Entry of Appearance as
Attorney or Accredited Representative, with this
application.

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

Preparer's Certification

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

2.

Preparer's Business or Organization Name (if any)

Preparer's Mailing Address
3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

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
9.a. Preparer's Signature

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

3.e. ZIP Code

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

Province

3.g. Postal Code
3.h. Country

Form I-910 12/23/16 N

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5.a. Page Number

Part 9. 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 CSID 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.

3.d.

3.b. Part Number

6.a. Page Number

3.c. Item Number

4.b. Part Number

4.c. Item Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

7.a. Page Number
4.a. Page Number

5.c. Item Number

5.d.

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CSID Number (if any)

3.a. Page Number

5.b. Part Number

7.d.

4.d.

Form I-910 12/23/16 N

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