Part 3. Information
About Your Eligibility Category
|
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
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.
[New]
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.
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 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
3.
(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.)
Yes
No
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
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.
[fillable
field]
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.
|
Pages 5-6,
Part
7. Contact Information, Declaration, and Signature of the Person
Preparing this Application, If Other Than the Applicant
|
[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)
|
[Page 7]
[No change]
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.
[No change]
|