Pages 1-3,
Part 2. Information
About You
|
[Page 1]
Part 2. Information About You
Your Full Legal Name
1.a. Family Name (Last
Name)
1.b. Given Name (First
Name)
1.c. Middle Name
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 6. Additional Information.
2.a. Family Name (Last Name)
2.b. Given Name (First Name)
2.c. Middle Name
3.a. Family Name (Last Name)
3.b. Given Name (First Name)
3.c. Middle Name
4.a. Family Name (Last Name)
4.b. Given Name (First Name)
4.c. Middle Name
[Page 2]
Your U.S. Mailing Address
5.a. In Care Of Name (if any)
5.b. Street Number and Name
5.c. Apt./Ste./Flr. [Number]
5.d. City or Town
5.e. State
5.f. ZIP Code
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.
U.S. Physical Address
7.a. Street Number and Name
7.b. Apt./Ste./Flr. [Number]
7.c. City or Town
7.d. State
7.e. ZIP Code
Other Information
8. Alien Registration Number
(A-Number) (if any)
9. USCIS Online Account
Number (if any)
10. Gender
Male
Female
11. Marital Status
Single
Married
Divorced
Widowed
[Page 3]
Place of Birth
List the city/town/village,
state/province, and country where you were born.
19.a. City/Town/Village of
Birth
19.b. State/Province of Birth
19.c. Country of Birth
20. Date of Birth
(mm/dd/yyyy)
[Page 2]
Your Country or Countries of
Citizenship or Nationality
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
18.b. Country
12. Have you previously filed
Form I-765?
Yes
No
[Page 3]
Information About Your Last
Arrival in the United States
21.a. Form I-94
Arrival-Departure Record Number (if any)
21.b. Passport Number of Your
Most Recently Issued Passport
21.c. Travel Document Number
(if any)
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)
26. Student and Exchange
Visitor Information System (SEVIS) Number (if any)
Information About Your
Eligibility Category
27. 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)).
[Three fillable fields separated by
parenthesis]
28. (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.
28.a. Degree
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. (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.
30. (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.
[moved from
above]
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 2]
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.
13.b. Provide your Social
Security number (SSN) (if known).
14. 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
No
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.
15. 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
Provide your father's birth name.
16.a. Family Name (Last Name)
16.b. Given Name (First Name)
Mother's Name
Provide your mother's birth name.
17.a. Family Name (Last Name)
17.b. Given Name (First Name)
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[Page 1]
Part 2. Information About You
1.
Your Full Legal Name
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
2.
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 6. Additional Information.
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
[Page 2]
3.
Your U.S. Mailing Address or Safe
Mailing Address
In Care
Of Name (if any)
Street Number
and Name
Apt./Ste./Flr.
Number
City or
Town
State
ZIP Code
4.
Is this a safe mailing address?
Yes
No
5. Is
your current mailing address or safe mailing
address the same as your physical address?
Yes
No
NOTE: If you answered “No”
to Item Number 5.,
provide your physical address below.
6. U.S.
Physical Address
Street Number
and Name
Apt./Ste./Flr.
Number
City or
Town
State
ZIP Code
Other Information
7. Alien
Registration Number (A-Number) (if any)
8. USCIS
Online Account Number (if any)
9. Gender
Male
Female
10. Marital
Status
Single
Married
Divorced
Widowed
11. Place
of Birth
List the
city/town/village, state/province, and country where you were
born.
A.
City/Town/Village of Birth
B.
State/Province of Birth
C. Country
of Birth
12. Date
of Birth (mm/dd/yyyy)
13.
Your Country or Countries of Citizenship or Nationality
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.
A. Country
B. Country
14. Have
you previously filed Form I-765?
Yes
No
[Page 3]
Information About Your Last
Arrival in the United States
15.A. Form
I-94 Arrival-Departure Record Number (if any)
B. Passport
Number of Your Most Recently Issued Passport
C. Travel
Document Number (if any)
D. Country
That Issued Your Passport or Travel Document
E.
Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
16. Date
of Your Last Arrival Into the United States, On or About
(mm/dd/yyyy)
17. Place
of Your Last Arrival Into the United States
18.
Immigration Status at Your Last Arrival (for example,
B-2 visitor, F-1 student, or no status)
19. Your
Current Immigration Status or Category (for example, F-1 student,
parolee, deferred action, or no status or category)
20. Student
and Exchange Visitor Information System (SEVIS) Number (if any)
Part 3.
Information About Your Eligibility Category
1.
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)).
[Three fillable fields separated by
parenthesis]
2.
(c)(3)(C) STEM OPT Eligibility Category. If you
entered the eligibility category (c)(3)(C) in Item
Number
1.,
provide the information requested in Items
A. - C.
A. Degree
B.
Employer's Name as Listed in E-Verify
C.
Employer's E-Verify Company Identification Number or a
Valid E-Verify Client Company Identification Number
[moved down]
3.A.
(c)(8) Eligibility Category. If
you entered the (c)(8) eligibility category in Item
Number 1., are you
are eligible for benefits under the ABC settlement agreement as a
Salvadoran or Guatemalan national?
Yes
No
B. If
you entered the eligibility category (c)(8) in Item Number 1.,
have you EVER been arrested for and/or convicted of any
crime?
Yes
No
NOTE: If you answered “Yes”
to Item B., in
Item Number 3.,
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.
4. (c)(26)
Eligibility Category. If you
entered the eligibility category (c)(26) in Item
Number 1., provide the receipt
number of your H1-B spouse’s most recent Form I-797 Notice
for Form I-129, Petition for a Nonimmigrant Worker.
[Page 4]
5.A.
(c)(35) and (c)(36) Eligibility Category. If you
entered the eligibility category (c)(35) in Item Number 1.,
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 1.,
please provide the receipt number of your spouse's or parent's
Form I-797 Notice for Form I-140.
B. If
you entered the eligibility category (c)(35) or (c)(36) in
Item Number 1., have
you EVER been arrested for and/or convicted of any crime?
Yes
No
NOTE: If you answered “Yes”
to Item B. in
Item Number 5.,
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.
Part 4.
Social Security Card Information
1.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 A.
in Item Number 1.,
skip to Item Number 2. If
you answered “Yes” to Item A.
in Item Number 1.,
provide the information requested in Item
B. below.
B. Provide
your Social Security number (SSN) (if known).
2. Do
you want the SSA to issue you a Social Security card? (You must
also answer “Yes” to Item Number 3.,
Consent for Disclosure, to receive a card.)
Yes
No
NOTE: If you answered “No”
to Item Number 2., skip
to Part 5. If
you answered “Yes” to Item Number 2.,
you must also answer “Yes” to Item Number 3.
3. 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 2. -
3., provide the
information requested in Item Numbers 4.
- 5.
4. Father's
Name
Provide your father's birth name.
Family Name
(Last Name)
Given Name
(First Name)
5. Mother's
Name
Provide your mother's birth name.
Family Name
(Last Name)
Given Name
(First Name)
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Page 4,
Part
3. Applicant's Statement, Contact Information, Declaration,
Certification, and Signature
|
[Page 4]
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.
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 4. read to me every question and instruction on this
application and my answer to every question in [Fillable field], a
language in which I am fluent, and I understood everything.
2. At my request, the
preparer named in Part 5., [Fillable field], 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)
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.
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:
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.
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.
|
[Page 5]
Part 5.
Applicant's Statement, Contact Information,
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.
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 4. read to me every question and
instruction on this application and my answer to every question in
[Fillable field], a language in which I am fluent, and I
understood everything.
2.
Applicant’s Statement Regarding the Preparer
At my
request, the preparer named in Part 5., [Fillable field],
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)
[delete]
Applicant's
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.
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:
1) I reviewed and provided
or authorized all of the information in
my application;
2)
I understood all of the information contained in, and submitted
with, my application; and
3) All
of this information was complete, true, and correct at the time of
filing.
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.
Applicant's Signature
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.
|
Pages 4-5,
Part
4. Interpreter's Contact Information, Certification, and
Signature
|
[Page 4]
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. Interpreter's Business or
Organization Name (if any)
[Page 5]
Interpreter's Mailing Address
3.a. Street Number and Name
3.b. Apt./Ste./Flr. [Number]
3.c. City or Town
3.d. State
3.e. ZIP Code
3.f. Province
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)
6. Interpreter's Email
Address (if any)
Interpreter's Certification
I certify, under penalty of perjury,
that:
I am fluent in English and [Fillable
field], 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
7.a. Interpreter's Signature
7.b. Date of Signature
(mm/dd/yyyy)
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[Page 6]
Part 6.
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)
[Page 5]
Interpreter's Mailing Address
3.
Street
Number and Name
Apt./Ste./Flr.
Number
City
or
Town
State
ZIP
Code
Province
Postal
Code
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)
Interpreter's Certification
I certify, under penalty of perjury,
that:
I am fluent in English and [Fillable
field], which is the same language specified in Part 5.,
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)
|
Pages 5-6,
Part
5. Contact Information, Declaration, and Signature of the Person
Preparing this Application, If Other Than the Applicant
|
[Page 5]
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
1.a. Preparer's Family Name
(Last Name)
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. [Number]
3.c. City or Town
3.d. State
3.e. ZIP Code
3.f. Province
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)
[Page 6]
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.
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)
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[Page 7]
Part 7.
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
1.
Preparer’s
Family Name (Last Name)
Preparer’s
Given
Name (First 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
ZIP
Code
Province
Postal
Code
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.
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 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
8.
Preparer's Signature
Date of
Signature (mm/dd/yyyy)
|