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

Authorization/Extension
Valid Through

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05/18/2020

Alien Registration Number
Remarks

A-

To be completed by an attorney or
Board of Immigration Appeals (BIA)accredited representative (if any).

Select this box if Form G-28
is attached.

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

Part 1. Reason for Applying

Other Names Used

I am applying for (select only one box):

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 7.
Additional Information.

1.a.

Initial permission to accept employment.

1.b.

Replacement of lost, stolen, or damaged employment
authorization document, or correction of my
employment authorization document NOT DUE to
U.S. Citizenship and Immigration Services (USCIS)
error.

1.c.

2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)

NOTE: Replacement (correction) of an employment
authorization document due to USCIS error does not
require a new Form I-765 and filing fee. Refer to
Replacement for Card Error in the What is the
Filing Fee section of the Form I-765 Instructions for
further details.

2.c. Middle Name

Renewal of my permission to accept employment.
(Attach a copy of your previous employment
authorization document.)

3.c. Middle Name

Part 2. Information About You
Your Full Legal Name

3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)

4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c. Middle Name

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name

Form I-765 12/26/19

Page 1 of 7

Part 2. Information About You (continued)

13.b. Provide your Social Security number (SSN) (if known).
►

Your U.S. Mailing Address

14.

5.a. In Care Of Name (if any)

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

5.b. Street Number
and Name
5.c.

Apt.

Ste.

5.d. City or Town

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.

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15.

5.e. State

5.f.

ZIP Code

(USPS ZIP Code Lookup)

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.

7.b.

Apt.

Ste.

Provide your father's birth name.

9.

Flr.

Provide your mother's birth name.
17.a. Family Name
(Last Name)
17.b. Given Name
(First Name)

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

Your Country or Countries of Citizenship or
Nationality

USCIS Online Account Number (if any)
►

10.

Gender

11.

Marital Status
Single

12.

16.a. Family Name
(Last Name)
16.b. Given Name
(First Name)

7.e. ZIP Code

Other Information
8.

NOTE: If you answered “Yes” to Item Numbers
14. - 15., provide the information requested in Item
Numbers 16.a. - 17.b.

Mother's Name

7.c. City or Town
7.d. State

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

Father's Name

U.S. Physical Address
7.a. Street Number
and Name

No

Male

Female

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 7. Additional Information.
18.a. Country

Married

Divorced

Widowed
18.b. Country

Have you previously filed Form I-765?
Yes

No

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.

Form I-765 12/26/19

Page 2 of 7

Part 2. Information About You (continued)

Information About Your Eligibility Category
27.

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

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)).

19.a. City/Town/Village of Birth

(
28.

19.c. Country of Birth

)(

)

(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.

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19.b. State/Province of Birth

)(

28.a. Degree

28.b. Employer's Name as Listed in E-Verify

20.

Date of Birth (mm/dd/yyyy)

Information About Your Last Arrival in the
United States

21.a. Form I-94 Arrival-Departure Record Number (if any)
►

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

29.

21.b. Passport Number of Your Most Recently Issued Passport

►

21.c. Travel Document Number (if any)

30.

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)
► N-

Form I-765 12/26/19

(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.

(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.

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 3 of 7

2.

Part 3. Biographic Information
1.

2.

,

Ethnicity (Select only one box)
Hispanic or Latino

At my request, the preparer named in Part 6.,
prepared this application for me based only upon
information I provided or authorized.

Not Hispanic or Latino

Race (Select all applicable boxes)

Applicant's Contact Information

American Indian or Alaska Native

3.

Asian

Applicant's Daytime Telephone Number

Black or African American

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Native Hawaiian or Other Pacific Islander
White
3.

Height

4.

Weight

5.

Eye Color (Select only one box)
Black
Gray
Maroon

6.

Feet

Inches

Pounds

Brown
Sandy

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.

Blue

Brown

Green

Hazel

Applicant's Declaration and Certification

Pink

Unknown/Other

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.

Hair Color (Select only one box)
Bald (No hair)

4.

Black

Blond

Gray

Red

White

Unknown/Other

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.

Part 4. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature

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.

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
Applicant's Signature

NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
1.a.

1.b.

7.a. Applicant's Signature

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.

7.b. Date of Signature (mm/dd/yyyy)

The interpreter named in Part 5. read to me every
question and instruction on this application and my
answer to every question in

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.
,

a language in which I am fluent, and I understood
everything.

Form I-765 12/26/19

Page 4 of 7

Interpreter's Certification

Part 5. Interpreter's Contact Information,
Certification, and Signature

I certify, under penalty of perjury, that:

Provide the following information about the interpreter.

I am fluent in English and

Interpreter's Full Name
1.a. Interpreter's Family Name (Last Name)

which is the same language specified in Part 4., 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.

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1.b. Interpreter's Given Name (First Name)

2.

,

Interpreter's Business or Organization Name (if any)

Interpreter's Signature

7.a. Interpreter's Signature

Interpreter's Mailing Address
3.a. Street Number
and Name
3.b.

Apt.

Ste.

3.c. City or Town
3.d. State
3.f.

Province

3.g. Postal Code
3.h. Country

Flr.

3.e. ZIP Code

7.b. Date of Signature (mm/dd/yyyy)

Part 6. 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)

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Mobile Telephone Number (if any)

2.

Preparer's Business or Organization Name (if any)

Preparer's Mailing Address
3.a. Street Number
and Name

6.

Interpreter's Email Address (if any)

3.b.

Apt.

Ste.

Flr.

3.c. City or Town
3.d. State
3.f.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Form I-765 12/26/19

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Part 6. 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

5.

Preparer's Mobile Telephone Number (if any)

6.

Preparer's Email Address (if any)

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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
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 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)

Form I-765 12/26/19

Page 6 of 7

5.a. Page Number

Part 7. 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.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.

5.b. Part Number

5.c. Item Number

5.d.

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A-Number (if any) ► A-

3.a. Page Number

3.d.

4.a. Page Number

4.d.

Form I-765 12/26/19

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

4.b. Part Number

4.c. Item Number

7.a. Page Number

7.d.

Page 7 of 7