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

Barcode

OMB No. 1615-0114
Expires 05/31/2020

Action Block

Resubmitted

Received
Sent

Remarks

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CSID Number

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

Select this box if
Form G-28 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 (The Applicant)
1.

Have you ever been designated as a civil surgeon?

Yes

No

Yes

No

Yes

No

If you answered "Yes" to Item Number 1., provide the following information.
2.

Civil Surgeon Identification Number (CSID) (if known)

4.

Has USCIS ever revoked your designation?

3.

Period of Designation (mm/dd/yyyy)
From
To

If you answered "Yes" to Item Number 4., provide the following information.
5.

Date of Revocation (mm/dd/yyyy)

6.

Have you ever voluntarily terminated your designation?

If you answered "Yes" to Item Number 6., provide the following information.
7.

Date of Voluntary Termination (mm/dd/yyyy)

NOTE: If you answered "Yes" to Item Number 4. or Item Number 6., include a typed or printed explanation of the circumstances
surrounding the revocation or voluntary termination in Part 10. Additional Information.
8.

Your Full Legal Name (Do not provide a nickname)
Family Name (Last Name)

Form I-910 05/29/18

Given Name (First Name)

Middle Name (if applicable)

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Part 1. Information About You (The Applicant) (continued)
Other Information
9.

Other Names Used (if any)
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 10. Additional Information.
Family Name (Last Name)

Given Name (First Name)

10. Date of Birth (mm/dd/yyyy)

11. Gender

Female

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12. USCIS Online Account Number (if any)
►

Male

Middle Name (if applicable)

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

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 examinations in more than one location, provide the details for each additional location in the space
provided in Part 10. Additional Information.
You must provide the following information. Failure to provide this information may result in the denial of your application. USCIS
displays information regarding a clinic/practice location and contact information on our website for people who want to find a civil
surgeon. USCIS will use the contact information listed below for all civil surgeon-related communications.
1.

Name of Clinic/Practice

2.

Physical Address of the Clinic/Practice

(USPS ZIP Code Lookup)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

3.

County of Practice

4.

Telephone Number

7.

Website Address (URL) (if any)

9.

Physician Email Address (for USCIS use)

5.

Fax Number (if any)

6.

8.

ZIP Code

Email Address

Additional Languages Spoken (if any)

10. Is the clinic's physical address the same as the clinic's mailing address?

Yes

No

If you answered "No" to Item Number 10., provide the clinic's mailing address in Item Number 11.

Form I-910 05/29/18

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Part 2. Clinical Office Locations (continued)
11. Mailing Address of the Clinic/Practice
In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

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Part 3. Information About Your Status in the United States

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.)
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 an unexpired 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.)

3.

A.

I am currently present in the United States as a nonimmigrant. Provide the information requested in Items B. - H. in
Item Number 3. (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.)

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

D. Passport or Travel Document Number

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

C. Form I-94 Arrival-Departure Record Number (if any)
►
E. Country of Issuance for Passport or Travel Document

G. Current Nonimmigrant
Status

H. 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.)

Yes

No

Part 4. 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 your medical degree and complete the chart below.
Name of School

Form I-910 05/29/18

Dates of Attendance
(mm/dd/yyyy)
From
To

Graduation
Date
(mm/dd/yyyy)

Degree

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Part 5. Medical Licenses
You must have an active and unrestricted license to practice medicine in the state or U.S. territory where 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 10. Additional Information.
State or
U.S. Territory

Medical License Number

Date Issue
(mm/dd/yyyy)

Date Expires
(mm/dd/yyyy)

Good Standing?
(Y/N)

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Yes

No

Yes

No

Yes

No

Yes

No

If your medical license is restricted, temporary, or not in good standing; include any relevant documentation and a typed or printed
explanation of the circumstances in Part 10. Additional Information.

Part 6. Professional Experience

You must establish that you have practiced medicine as a physician (M.D. or D.O.) in the U.S. 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.
Submit evidence to establish your professional experience, such as letters of employment verification, evaluations, certificates of
completion, business tax returns and the business license covering tax returns period (for self-employed physicians), or medical
liability or malpractice insurance policy. A medical liability/malpractice insurance policy, by itself, is insufficient to establish
professional experience, but may be submitted to supplement other evidence listed above. If you need extra space to complete this
section, use the space provided in Part 10. Additional Information.
Employer 1
1.

Employer's Name

Dates of Employment (mm/dd/yyyy)
From

Employer's Daytime Telephone Number

To

Employer's Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Form I-910 05/29/18

ZIP Code

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Part 6. Professional Experience (continued)
Employer 2
2.

Employer's Name

Dates of Employment (mm/dd/yyyy)
From
To

Employer's Daytime Telephone Number

Employer's Address
Street Number and Name

City or Town

Apt. Ste. Flr. Number

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State

ZIP Code

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

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.

Applicant's Statement

NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1.

Applicant's Statement Regarding the Interpreter
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.

B.

The interpreter named in Part 8. 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 understand everything.
2.

Applicant's Statement Regarding the Preparer

, prepared this application for me

At my request, the preparer named in Part 9.,

based only upon information I provided or authorized.

Applicant's Contact Information
3.

Applicant's Daytime Telephone Number

5.

Applicant's Email Address (if any)

Form I-910 05/29/18

4.

Applicant's Mobile Telephone Number (if any)

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Part 7. Applicant's Statement, Contact Information, Certification, and Signature (continued)
Applicant's Certification
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” published by the Centers for Disease Control and
Prevention (CDC).
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.
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.

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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.
I certify, under penalty of perjury, that I provided or authorized all of the information in my application, I 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
6.

Date of Signature (mm/dd/yyyy)

Applicant's Signature

Your signature will be kept on record to verify the signature on any submitted Form I-693.

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. Interpreter's Contact Information, Certification, and Signature
Provide the following information about the interpreter.

Interpreter's Full Name

1. Interpreter's Family Name (Last Name)

Interpreter's Given Name (First Name)

2. Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Form I-910 05/29/18

Postal Code

ZIP Code

Country

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Part 8. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

6.

Interpreter's Email Address (if any)

5.

Interpreter's Mobile Telephone Number (if any)

Interpreter's Certification
I certify, under penalty of perjury, that:

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I am fluent in English and

which is the same language specified in Part 7.,

Item B. in Item Number 1., 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 Certification, and has verified the accuracy of every answer.

Interpreter's Signature
7.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Part 9. 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 Given Name (First Name)

1.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization Name (if any)

Preparer's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Form I-910 05/29/18

Postal Code

ZIP Code

Country

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Part 9. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Applicant (continued)
Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

7.

5.

Preparer's Mobile Telephone Number (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.

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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.

B.

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

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.

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 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.

Preparer's Signature

Form I-910 05/29/18

Date of Signature (mm/dd/yyyy)

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Part 10. 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.

Family Name (Last Name)

2.

CSID Number (if any)

3.

A. Page Number

D.

4.

5.

A. Page Number

D.

6.

Middle Name

B. Part Number C. Item Number

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A. Page Number

D.

Given Name (First Name)

A. Page Number

B. Part Number C. Item Number

B. Part Number C. Item Number

B. Part Number C. Item Number

D.

7.

A. Page Number

B. Part Number C. Item Number

D.

Form I-910 05/29/18

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