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

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Authorization/Extension
Valid Through

Alien Registration Number

A-

Remarks

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. Reason for Applying
1.

I am applying for (select only one box):
A.
B.

An initial employment authorization document.
Replacement of:
(1)

Lost employment authorization document.

(2)

Stolen employment authorization document.

(3)

Damaged employment authorization document.

(4)

Correction of my employment authorization document NOT DUE to U.S. Citizenship and Immigration
Services (USCIS) error.

NOTE: For more information about replacement or correction of an employment authorization document, including
due to USCIS error, refer to Replacement for Card Error in the What Is the Filing Fee section of the Form I-765
Instructions.
C.

Renewal of my employment authorization document.

Part 2. Information About You
1.

Your Full Legal Name
Family Name (Last Name)

2.

Given Name (First Name)

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.
Family Name (Last Name)

Form I-765 12/26/19

Given Name (First Name)

Middle Name

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Part 2. Information About You (continued)
3.

Your U.S. Mailing Address or Safe Mailing Address
In Care Of Name (if any)

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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)
►

9.

11.

A-

Gender
Male

10.

Female

8.

Marital Status
Single
Married

USCIS Online Account Number (if any)
►

Divorced

Widowed

Place of Birth

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

City/Town/Village of Birth

C.

Country of Birth

12.

Date of Birth (mm/dd/yyyy)

13.

Your Country or Countries of Citizenship or Nationality

B.

State/Province of Birth

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.

14.

Country

Have you previously filed Form I-765?

Form I-765 12/26/19

B.

Country

Yes

No

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Part 2. Information About You (continued)
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)

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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)

► N-

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)).
(
)(
)(
)

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.

3.

A.

Degree

C.

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

B.

Employer's Name as Listed in E-Verify

(c)(8) Eligibility Category. If you entered the eligibility category (c)(8) in Item Number 1., provide the information requested
in Items A. - D.
A.

(c)(8) Eligibility Category. If you entered the (c)(8) eligibility category in Item Number 1., are you
eligible for benefits under the ABC settlement agreement as a Salvadoran or Guatemalan national?

Yes

No

B.

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 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.
C.

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

Form I-765 12/26/19

Yes

No

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Part 3. Information About Your Eligibility Category (continued)
D.

If you answered “No” to Item C., did you present yourself to the Secretary of Homeland Security or
his or her delegate (DHS) 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

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If you answered “Yes” to Item D., provide the following information:
Date you presented yourself to DHS

Location where you presented yourself to DHS

Country of claimed persecution

Provide an explanation for why you did not enter the United States lawfully through a U.S. port of entry. If you need
extra space to complete this item, use the space provided in Part 8. Additional Information.

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.
4.

(c)(26) Eligibility Category. If you entered the eligibility category (c)(26) in Item Number 1., 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.
►

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). ►

Form I-765 12/26/19

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Part 4. Social Security Card Information (continued)
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.

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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)

5.

Given Name (First Name)

Mother's Name

Provide your mother's birth name.
Family Name (Last Name)

Given Name (First Name)

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.

2.

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

Applicant's Statement Regarding the Preparer
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

5.

Applicant's Email Address (if any)

Form I-765 12/26/19

4.

Applicant's Mobile Telephone Number (if any)

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Part 5. Applicant's Statement, Contact Information, Certification, and Signature (continued)
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.

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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 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.

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)

Interpreter's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Form I-765 12/26/19

Postal Code

ZIP Code

Country

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Part 6. 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)

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Interpreter's Certification

I certify, under penalty of perjury, that:
I am fluent in English and

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
declaration and his or her answer to every question. The applicant informed me that he or she understands every instruction, question,
and answer on the declaration, 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 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

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-765 12/26/19

Postal Code

ZIP Code

Country

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Part 7. 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)

5.

Preparer's Mobile Telephone Number (if any)

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Preparer's Statement
7.

A.

I am not an attorney or accredited representative but have prepared this declaration on behalf of the declarant and with
the declarant's consent.

B.

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

NOTE: If you are an attorney or accredited representative, you 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

Form I-765 12/26/19

Date of Signature (mm/dd/yyyy)

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Part 8. 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.

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1.

Family Name (Last Name)

2.

A-Number (if any) ► A-

3.

A.

D.

4.

A.

D.

5.

A.

Given Name (First Name)

Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

Middle Name

D.

6.

A.

D.

Form I-765 12/26/19

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