Form I-212 Application for Permission to Reapply for Admission into

Application for Permission to Reapply for Admission
Into the United States After Deportation or Removal
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-212

OMB No. 1615-0018
Expires 06/30/2017

For DHS Use Only
Alien Registration Number

Fee Stamp

Action Block

AInitial Receipt

Transferred In

Relocated Returned

Approved
INA 212(a)(9)(A) for Advance
Approval
INA 212(a)(9)(A)

Remarks
DHS Office Name/Location

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INA 212(a)(9)(C)

Transferred Out

Denied

To be completed by an
Attorney or Accredited
Representative (if any).

Select this box if
Form G-28 or
Form G-28I is
attached.

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
1.

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

Your Full Name

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

4.c. Middle Name

Mailing Address

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

NOTE: If you are outside the United States, provide a U.S.
mailing address, if available. If a U.S. mailing address is not
available, provide your mailing address abroad.

2.c. Middle Name

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

Other Names Used

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

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

Ste.

Flr.

5.d. City or Town
5.e. State

5.f.

ZIP Code

5.g. Province
5.h. Postal Code
5.i.

Form I-212 12/23/16 N

Apt.

Country

Page 1 of 11

Part 1. Information About You (continued)
6.

Is your mailing address the same address where you
currently live (physical address)?
Yes
No
If you answered "No" to Item Number 6., provide your
current physical address in Item Numbers 7.a. - 7.f.

Physical Address

Apt.

Ste.

7.f.

Province

The Department of State (DOS) Consular Case Number
(if available)

17.a. City or Town

Flr.

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

16.

The Location of the U.S. Embassy or U.S. Consulate Where
Your Application for an Immigrant Visa is Being or Will Be
Made

7.a. Street Number
and Name
7.b.

If you seek an immigrant or nonimmigrant visa and you are or
will file your application for consent to reapply with your
immigrant or nonimmigrant visa application, provide the
information requested in Item Numbers 16. - 17.b.

17.b. Country

7.e. ZIP Code

7.g. Postal Code

If you are seeking consent to reapply in connection with your
application to adjust your status to that of a lawful permanent
resident, provide information in Item Numbers 18.a. - 18.c.

7.h. Country

18.a. USCIS Receipt Number (if any)

Other Information About You
8.

U.S. Social Security Number (if any)
►

9.

18.b. Where did you file your application (for example,
"USCIS Office Name" or "Lockbox")?

18.c. Date Filed (mm/dd/yyyy)

U.S. Online Account Number (if any)
►

10.

Gender

11.

Date of Birth (mm/dd/yyyy)

12.

City or Town of Birth

13.

State or Province of Birth (if applicable)

14.

Country of Birth

15.

Country of Citizenship or Nationality

Male

Form I-212 12/23/16 N

19.

Are you submitting Form I-601, Application for Waiver
of Grounds of Inadmissibility, along with this application?

Female

Yes

No

If you answered "No," provide the information requested
in Item Numbers 20.a. - 20.c. about previously filed
Forms I-601 (if any):

20.a. USCIS Receipt Number for Form I-601 (if any)
20.b. Where did you file your application (for example,
"USCIS Office Name" or "Lockbox")?

20.c. Date Filed (mm/dd/yyyy)

Page 2 of 11

Part 2. Reasons You Are Filing Form I-212
If you are inadmissible to the United States for the following
reason, select “Yes” and then select the appropriate boxes. If
you need extra space to complete this section, use the space
provided in Part 9. Additional Information.

Removal as an Arriving Alien (INA Section
212(a)(9)(A)(i))
1.a. I have been removed as an arriving alien in expedited
removal proceedings under INA section 235(b)(1) or I
was removed at the end of proceedings under INA section
240 as an arriving alien.
Yes
No
I have only been removed once, and my last removal
was less than five years ago.

1.c.

I have been removed at least two or more times, and
my last removal was less than 20 years ago.

1.d.

I have been convicted of an aggravated felony in the
United States or abroad, before or after my removal
from the United States. Provide information on your
aggravated felony convictions in Part 9. Additional
Information and include the required evidence.
Date You Were Removed From the United States
(mm/dd/yyyy)

Location From Where You Were Removed
3.

7.a. City or Town
7.b. State

Entry After Unlawful Presence in the Aggregate of
1 Year (INA Section 212(a)(9)(C)(i)(I))
8.

City or Town
State

Removal as a Deportable Alien (INA Section
212(a)(9)(A)(ii))

5.a. I have been removed as a deportable alien under INA
section 240 or any other provision of the law, or I
departed the United States while an order of removal was
outstanding.
Yes
No
5.b.

I have only been removed once and my removal was
less than 10 years ago.

5.c.

I have been removed two or more times, and my last
removal was less than 20 years ago.

5.d.

I have been convicted of an aggravated felony in the
United States or abroad, before or after my removal
from the United States. Provide information on your
aggravated felony convictions in Part 9. Additional
Information and include the required evidence.

6.

Date You Were Excluded, Deported, or Removed From
the United States (mm/dd/yyyy)

Form I-212 12/23/16 N

Yes

No

NOTE: If you answered "Yes" to Item Number 8., list
all the time periods during which you were unlawfully
present in the United States (including any periods in
which you overstayed your lawful status). Begin with
your most recent period of unlawful presence. Also
attach evidence demonstrating that you have remained
outside the United States for 10 years since your last
departure.

Periods of Unlawful Presence
9.a. From (mm/dd/yyyy)
9.b. To (mm/dd/yyyy)

10.

4.

I entered or attempted to enter the United States without
being admitted or paroled, after having been unlawfully
present in the United States on or after April 1, 1997, for a
period of more than one year, in the aggregate.

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1.b.

2.

Location From Where You Were Removed

Date You Departed the United States After Your Period
of Unlawful Presence (mm/dd/yyyy)

Location Where You Departed the United States After Your
Period of Unlawful Presence
11.a. City or Town
11.b. State

Location Where You Reentered or Attempted to Reenter the
United States
12.a. City or Town
12.b. State
13.

Date You Attempted to Unlawfully Enter or Reenter the
United States After Period of Unlawful Presence
(mm/dd/yyyy)

Page 3 of 11

Part 2. Reasons You Are Filing Form I-212
(continued)

U.S. Citizen or Lawful Permanent Resident Family
Members (if any)

Entry After Removal (INA Section
212(a)(9)(C)(i)(II))

NOTE: If you need extra space to complete this section, use
the space provided in Part 9. Additional Information.

14.

I entered or attempted to enter the United States without
being admitted or paroled after having been excluded,
deported, or removed.
Yes
No
NOTE: If you answered “Yes” to Item Number 14., list
all the dates when you were excluded, deported, or
removed from the United States. If you need extra space
to complete this section, use the space provided in Part 9.
Additional Information.

15.

3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name
3.d. Relationship

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Date You Were Excluded, Deported, or Removed From
the United States (mm/dd/yyyy)

Location Where You Reentered or Attempted to Reenter the
United States After Your Exclusion, Deportation, or Removal
16.a. City or Town

My relative is (Select one):
A lawful permanent resident.
4.a.
4.b.

Part 4. Biographic Information

1.

16.b. State

A U.S. citizen.

Ethnicity (Select only one box)
Hispanic or Latino
Not Hispanic or Latino

17.

Date You Entered or Attempted to Reenter the United
States After Exclusion, Deportation, or Removal
(mm/dd/yyyy)

2.

Asian

Black or African American

Part 3. Reasons For Your Request For
Permission to Reapply

If the Department of Homeland Security (DHS) permits you to
reenter the United States, what immigration status will you seek?
1.a.

Permanent Resident

1.b.

Visitor

1.c.

Student

1.d.

Other (Explain)

2.

Explain Why You Would Like to Reenter the United
States
NOTE: If you need extra space to complete this section,
use the space provided in Part 9. Additional
Information.

Form I-212 12/23/16 N

Race (Select all applicable boxes)
White

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

3.

Height

4.

Weight

5.

Eye Color (Select only one box)
Black
Blue

6.

Feet

Inches

Pounds
Brown

Gray

Green

Hazel

Maroon

Pink

Unknown/Other

Hair Color (Select only one box)
Bald (No hair)
Black

Blond

Brown

Gray

Red

Sandy

White

Unknown/Other

Page 4 of 11

Part 5. Additional Information if Filing with
CBP
If you are filing this application with Customs and Border
Protection (CBP), provide the information requested in Item
Numbers 1.a. - 40.c.

Provide physical addresses for everywhere you have lived
during the last ten years, whether inside or outside the United
States. Provide your current address first. If you are unsure of
the exact date, provide the closest approximate date to the best
of your knowledge. If you need extra space to complete this
section, use the space provided in Part 9. Additional
Information.
1.a. Street Number
and Name

Ste.

Flr.

1.f.

Province

1.e. ZIP Code

Name of Employer or Company

Address of Employer or Company

6.b.

6.f.

Apt.

Ste.

Flr.

6.e. ZIP Code

Province

6.g. Postal Code
6.h. Country

2.a. From (mm/dd/yyyy)
2.b. To (mm/dd/yyyy)

7.

Physical Address 2

Your Occupation

Dates of Employment

3.a. Street Number
and Name
Apt.

5.

6.d. State

Dates of Residence

3.b.

Employer 1 (current or most recent)

6.c. City or Town

1.g. Postal Code
1.h. Country

Provide your employment history for the last five years,
whether inside or outside the United States. Provide the most
recent employment first. If you are unsure of the exact
employment date, provide the closest approximate date to the
best of your knowledge. If you need extra space to complete
this section, use the space provided in Part 9. Additional
Information.

6.a. Street Number
and Name

1.c. City or Town
1.d. State

4.b. To (mm/dd/yyyy)

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Physical Address 1 (current address)

Apt.

4.a. From (mm/dd/yyyy)

Employment History

Address History

1.b.

Dates of Residence

8.a. From (mm/dd/yyyy)

Ste.

Flr.

8.b. To (mm/dd/yyyy)

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

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Form I-212 12/23/16 N

Page 5 of 11

Part 5. Additional Information if Filing with
CBP (continued)

17.

Country of Birth

Employer 2

18.

Current City or Town of Residence (if living)

19.

Current Country of Residence (if living)

9.

Name of Employer or Company

Address of Employer or Company
10.a. Street Number
and Name
10.b.

Apt.

Information About Your Father

Ste.

Flr.

10.f. Province

10.e. ZIP Code

10.g. Postal Code
10.h. Country
11.

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

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10.c. City or Town
10.d. State

Father's Legal Name

Your Occupation

Dates of Employment

20.c. Middle Name

Father's Name at Birth (if different than above)
21.a. Family Name
(Last Name)
21.b. Given Name
(First Name)

21.c. Middle Name
22.

Date of Birth (mm/dd/yyyy)

23.

City or Town of Birth

24.

Country of Birth

25.

Current City or Town of Residence (if living)

26.

Current Country of Residence (if living)

12.a. From (mm/dd/yyyy)
12.b. To (mm/dd/yyyy)

Information About Your Parents
Information About Your Mother
Mother's Legal Name
13.a. Family Name
(Last Name)
13.b. Given Name
(First Name)

Information About Your Marital History

27.

13.c. Middle Name

What is your current marital status?
Single, Never Married

Legally Separated

Mother's Name at Birth (if different than above)

Married

Marriage Annulled

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

Divorced

Other

14.c. Middle Name
15.

Date of Birth (mm/dd/yyyy)

16.

City or Town of Birth

Form I-212 12/23/16 N

Widowed
28.

How many times have you been married (including
annulled marriages and marriages to the same person)?

Page 6 of 11

Part 5. Additional Information if Filing with
CBP (continued)
Information About Your Current Marriage
(including if you are legally separated)
If you are currently married, provide the following information
about your current spouse.
Current Spouse's Legal Name
29.a. Family Name
(Last Name)
29.b. Given Name
(First Name)

If you have been married before, whether in the United States or
in any other country, provide the following information about
your prior spouse. If you have had more than one previous
marriage, use the space provided in Part 9. Additional
Information to provide the information below.
Prior Spouse's Legal Name (provide family name before
marriage)
35.a. Family Name
(Last Name)
35.b. Given Name
(First Name)

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29.c. Middle Name
30.

A-Number (if any) ► A-

31.

Current Spouse's Date of Birth (mm/dd/yyyy)

32.

Date of Marriage to Current Spouse (mm/dd/yyyy)

Current Spouse's Place of Birth
33.a. City or Town

33.b. State or Province
33.c. Country

Information About Prior Marriages (if any)

35.c. Middle Name
36.

Prior Spouse's Date of Birth (mm/dd/yyyy)

37.

Date of Marriage to Prior Spouse (mm/dd/yyyy)

Place of Marriage to Prior Spouse

38.a. City or Town

38.b. State or Province
38.c. Country
39.

Date Marriage with Prior Spouse Legally Ended
(mm/dd/yyyy)

Place of Marriage to Current Spouse
34.a. City or Town

34.b. State or Province
34.c. Country

Form I-212 12/23/16 N

Place Where Marriage with Prior Spouse Legally Ended
40.a. City or Town

40.b. State or Province

40.c. Country

Page 7 of 11

Part 6. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature

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:

NOTE: Read the Penalties section of the Form I-212
Instructions before completing this part.

1) I reviewed and understood all of the information
contained in, and submitted with, my application; and
2) All of this information was complete, true, and correct
at the time of filing.

Applicant's Statement
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 7. read to me every
question and instruction on this application and my

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answer to every question in
a language in which I am fluent, and I understood
everything.
2.

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.

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

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

,

Applicant's Signature

6.a. Applicant's Signature

►

6.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.

Applicant's Contact Information
3.

Applicant's Daytime Telephone Number

Part 7. Interpreter's Contact Information,
Certification, and Signature

4.

Applicant's Mobile Telephone Number (if any)

Provide the following information about the interpreter.

5.

Applicant's Email Address (if any)

Applicant's Declaration and Certification

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.

Interpreter's Full Name

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

Interpreter's Business or Organization Name (if any)

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.

Form I-212 12/23/16 N

Page 8 of 11

Part 7. Interpreter's Contact Information,
Certification, and Signature (continued)

Part 8. 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.

Flr.

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

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

Province

3.e. ZIP Code

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

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2.

Preparer's Business or Organization Name (if any)

3.g. Postal Code
3.h. Country

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Mobile Telephone Number (if any)

Preparer's Mailing Address

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

Interpreter's Email Address (if any)

Ste.

Flr.

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

3.f.

6.

Apt.

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 6., 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-212 12/23/16 N

Page 9 of 11

Part 8. 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 representative, you
may be obliged to submit a completed Form G-28, Notice of
Entry of Appearance as Attorney or Accredited Representative,
or Form G-28I, Notice of Entry of Appearance as Attorney In
Matters Outside the Geographical Confines of the United States,
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-212 12/23/16 N

Page 10 of 11

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 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.

5.b. Part Number

5.c. Item Number

5.d.

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

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1.c. Middle Name
2.

A-Number (if any) ► A-

3.a. Page Number
3.d.

4.a. Page Number
4.d.

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

4.b. Part Number

Form I-212 12/23/16 N

4.c. Item Number

7.a. Page Number
7.d.

Page 11 of 11