Form I-905 Application for Authorization to Issue Certification for

OMB No. 1615-0086; Expires 06/30/09

I-905, Application for Authorization to
Issue Certification for Health Care Workers

Department of Homeland Security
U.S. Citizenship and Immigration Services

For USCIS Use Only

START HERE - Please type or print in black ink.
Part 1.

Information about the applicant filing this form.
Returned

Company or Organization

Receipt

Address
Street Number and Name

Room #

City

State

IRS Tax #
Phone # of Point of Contact
(
)

Resubmitted

Zip/Postal Code
Name of Point of Contact

Reloc Sent

Title of Point of Contact

Date organization was created.

Reloc Rec'd

Description of your organization.

Approved for all requested
occupations.
Partial approval (USCIS must list
approved occupations.)

Occupations for which you are seeking authorization.
Action Block

Describe the process you will use to issue certificates (If more space is required,
use a separate sheet(s) of paper).

Explain your organization's expertise, knowledge and experience in the health
care occupations for which you are seeking authorization.

To Be Completed by
Attorney or Representative, if any
Fill in box if G-28 is attached to
represent the petitioner
VOLAG#
ATTY State License #

Form I-905 (Rev. 07/30/07) Y

Explain how your organization meets the standards described in the instructions sheet. (If more space is required, attach a
separate sheet(s) of paper).

Describe the procedure you will establish for U.S. Citizenship and Immigration Services to use to verify the validity of
your certificates.

Part 2.

Signature. Read the information on penalties in the instructions before completing this section.

I certify, under penalty of perjury under the laws of the United States of America, that this application and the evidence submitted with it are all
true and correct. If filing this on behalf of an organization, I certify that I am empowered to do so by that organization. I authorize the release of
any information from my records or from the applicant's organization's records that U.S. Citizenship and Immigration Services needs to determine
eligibility for the benefit I am seeking. If this application is approved, I also agree to provide U.S. Citizenship and Immigration Services with any
information that it requests to determine the organization's eligibility to continue to issue certificates to health care workers.

Signature and Title

Print Name

Date

NOTE: If you do not completely fill out this form or fail to submit required documents listed in the instructions, this application
may be denied.

Part 3.

Signature of person preparing form, if other than above. (Sign below.)

I declare that I prepared this application at the request of the above person and it is based on all information of which I have
knowledge.
Signature

Print Name

Firm Name and Address (Street Number and Name; Daytime Telephone Number (Area Code
Suite/Room Number; City/Town; State; Zip Code
and Number)
(

)

Date

Fax Number (Area Code
and Number)
(

)

E-Mail Address (If any)

Form I-905 (Rev. 07/30/07) Y Page 2