Form 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

Authorization/Extension
Valid From

For
USCIS
Use
Only

Fee Stamp

OMB No. 1615-0040
Expires 05/31/2020

Action Block

Authorization/Extension
Valid Through

DRAFT
NOT FOR
PRODUCTION
10/28/2019

Alien Registration Number

A-

Remarks

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 05/31/18

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.c.

Apt.

Ste.

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.

Flr.

5.d. City or Town

15.

5.e. State

5.f.

ZIP Code

(USPS ZIP Code Lookup)

6.

No

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5.b. Street Number
and Name

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.

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
14. - 15., provide the information requested in Item
Numbers 16.a. - 17.b.

Father's Name

U.S. Physical Address

Provide your father's birth name.

7.a. Street Number
and Name

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

7.b.

Apt.

Ste.

Flr.

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

Mother's Name

Provide your mother's birth name.

7.e. ZIP Code

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

Other Information
8.

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

9.

USCIS Online Account Number (if any)
►

10.

Gender

11.

Marital Status
Single

12.

Your Country or Countries of Citizenship or
Nationality

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

Have you previously filed Form I-765?

18.b. Country
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 05/31/18

Page 2 of 7

Part 2. Information About You (continued)

If you are filing under the (c)(8) eligibility category, provide the
information requested in Item Numbers 27. - 29.d.

Place of Birth

27.

List the city/town/village, state/province, and country where
you were born.

Did you enter the United States lawfully through a Port of
Entry and were you admitted or paroled after inspection
by an immigration officer? (If you answer “Yes,” you
MUST provide evidence of your lawful entry.)

19.a. City/Town/Village of Birth

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28.

19.b. State/Province of Birth

19.c. Country of Birth

20.

Date of Birth (mm/dd/yyyy)

Information About Your Last Arrival in the
United States

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

Yes

No

If you answered “No” to Item Number 27., did you
present yourself to the Department of Homeland Security
within 48 hours of entry or attempted entry AND express
an intention to seek asylum within the United States or
express a fear of persecution or torture in your home
country?
Yes
No

If you answered “Yes” to Item Number 28., provide the
following information:
29.a. Date You Presented Yourself to DHS
(mm/dd/yyyy)

29.b. Location Where You Presented Yourself to DHS

29.c. Country of Claimed Persecution

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

21.c. Travel Document Number (if any)

29.d. Provide an explanation of why you did not enter the
United States lawfully through a U.S. port of entry. If
you need extra space to complete this section, use the
space provided in Part 6. Additional Information.

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)

NOTE: Refer to the Special Filing Instructions for Those
With Pending Asylum Applications (c)(8) section of the Form
I-765 Instructions for more information.

Information About Your Eligibility Category
25.

Your Current Immigration Status or Category (for example,
B-2 visitor, F-1 student, parolee, deferred action, or no
status or category)

26.

Student and Exchange Visitor Information System
(SEVIS) Number (if any)
► N-

Form I-765 05/31/18

30.

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)(3)(C) STEM OPT Eligibility Category. If you
entered the eligibility category (c)(3)(C) in Item Number
30., provide the information requested in Item Numbers
31.a. - 31.c.
Page 3 of 7

Part 2. Information About You (continued)
(c)(3)(C) STEM OPT Eligibility Category. If you entered the
eligibility category (c)(3)(C) in Item Number 30., provide the
information requested in Item Numbers 31.a. - 31.c.
31.a. Degree

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

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

Applicant's Statement

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

32.

(c)(26) Eligibility Category. If you entered the eligibility
category (c)(26) in Item Number 30., 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.

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

►
33.

(c)(8) Eligibility Category. If you entered the eligibility
category (c)(8) in Item Number 30., have you EVER
been arrested for, and/or charged with, and/or convicted
of any crime in any country?
Yes
No
NOTE: If you answered “Yes” to Item Number 33.,
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.

34.a. (c)(35) and (c)(36) Eligibility Category. If you entered
the eligibility category (c)(35) in Item Number 30., 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
30., please provide the receipt number of your spouse's or
parent's Form I-797 Notice for Form I-140.

,

a language in which I am fluent, and I understood
everything.

2.

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

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

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)

►
34.b. If you entered the eligibility category (c)(35) or (c)(36) in
Item Number 30., have you EVER been arrested for
and/or convicted of any crime?
Yes
No
NOTE: If you answered “Yes” to Item Number 34.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.

6.

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

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.
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-765 05/31/18

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Part 3. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
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:

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

Apt.

Ste.

Flr.

3.c. City or Town

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3.d. State

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

3.f.

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

3.g. Postal Code

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.

3.e. ZIP Code

Province

3.h. Country

Interpreter's Contact Information

4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

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.

Interpreter's Certification

I certify, under penalty of perjury, that:

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)

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.

Interpreter's Signature
1.b. Interpreter's Given Name (First Name)

2.

7.a. Interpreter's Signature

Interpreter's Business or Organization Name (if any)

Form I-765 05/31/18

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

Page 5 of 7

Part 5. 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

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.
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.

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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.

3.f.

Province

Preparer's Signature

8.a. Preparer's Signature

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

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.

3.e. ZIP Code

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

3.g. Postal Code
3.h. Country

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)

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.

Form I-765 05/31/18

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.

5.b. Part Number

5.c. Item Number

5.d.

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

1.c. Middle Name
2.

A-Number (if any) ► A-

3.a. Page Number

3.d.

4.a. Page Number

4.d.

Form I-765 05/31/18

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

4.c. Item Number

7.a. Page Number

7.d.

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