Form TOC

TABLE OF CHANGES – FORM

Form I-910, Application for Civil Surgeon Designation

OMB Number: 1615-0114

07/27/2020

Reason for Revision: Fee Rule

Project Phase: Post G-1056

• Please note – all instances of “if any” and “if applicable” have been removed from Form I-910.

Legend for Proposed Text:

• Black font = Current text

• Red font = Changes

Expires 07/31/2022

Edition Date 07/23/2020

Current Page Number and Section	Current Text	Proposed Text
Page 1	[Page 1] … To be completed by an attorney or accredited representative (if any). Select this box if Form G-28 is attached to represent the applicant. Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS Online Account Number (if any) START HERE - Type or print in black ink.	[Page 1] … To be completed by an attorney or accredited representative. Select this box if Form G-28 is attached to represent the applicant. Attorney State Bar Number Attorney or Accredited Representative USCIS Online Account Number START HERE - Type or print in black ink.
Pages 1-2, Part 1. Information About You (The Applicant)	[Page 1] … 8. Your Full Legal Name (Do not provide a nickname) Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) [Page 2] 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) [x2] Given Name (First Name) [x2] Middle Name (if applicable) [x2] 10. Date of Birth (mm/dd/yyyy) 11. Gender Male Female 12. USCIS Online Account Number (if any) 13. Alien Registration Number (A-Number) (if any)	[Page 1] … 8. Your Full Legal Name (Do not provide a nickname) Family Name (Last Name) Given Name (First Name) Middle Name [Page 2] Other Information 9. 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 10. Additional Information. Family Name (Last Name) [x2] Given Name (First Name) [x2] Middle Name [x2] 10. Date of Birth (mm/dd/yyyy) 11. Gender Male Female 12. USCIS Online Account Number 13. Alien Registration Number (A-Number)
Pages 2-3, Clinical Office Locations	[Page 2] … 3. County of Practice 4. Telephone Number 5. Fax Number (if any) 6. Email Address 7. Website Address (URL) (if any) 8. Additional Languages Spoken (if any) 9. Physician Email Address (for USCIS use) 10. Is the clinic’s physical address the same as the clinics mailing address? Yes No If you answered "No" to Item Number 10., provide the clinic’s mailing address in Item Number 11. [Page 3] 11. Mailing Address of the Clinic/Practice In Care Of Name (if any) Street Number and Name Apt./Ste./Flr. [Number] City or town County State ZIP Code	[Page 2] … 3. County of Practice 4. Telephone Number 5. Fax Number 6. Email Address 7. Website Address (URL) 8. Additional Languages Spoken 9. Physician Email Address (for USCIS use) 10. Is the clinic’s physical address the same as the clinics mailing address? Yes No If you answered "No" to Item Number 10., provide the clinic’s mailing address in Item Number 11. [Page 3] 11. Mailing Address of the Clinic/Practice In Care Of Name Street Number and Name Apt./Ste./Flr. [Number] City or town County State ZIP Code
Page 3, Part 3. Information About Your Status in the United States	[Page 3] … C. Form I-94 Arrival-Departure Record Number (if any) …	[Page 3] … C. Form I-94 Arrival-Departure Record Number …
Page 9, Part 10. Additional Information	[Page 9] 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)[Auto-populated field] Given Name (First Name)[Auto-populated field] Middle Name[Auto-populated field] 2. CSID Number (if any) [Auto-populate field with Item Number 2. in Part 1.] …	[Page 9] 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 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)[Auto-populated field] Given Name (First Name)[Auto-populated field] Middle Name[Auto-populated field] 2. CSID Number [Auto-populate field with Item Number 2. in Part 1.] …

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