I-910 Application for Civil Surgeon Designation

USCIS
Form I-910

Application for Civil Surgeon Designation
Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0114
Expires XX/XX/201X

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Initial Receipt
For
Resubmitted
USCIS
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Use
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Only

Action Block

Remarks

DRAFT
Not for
Production
05/03/13
CSID Number:

To Be Completed by an
Attorney or Representative, if any.

Fill in box if G-28 is attached to
represent the applicant.

Attorney State License Number:

► START HERE - Type or print in black ink.

Part 1. For Previously Designated Civil Surgeons
1.a. Have you ever been designated as a civil surgeon before?
Yes

No

If you checked "Yes," provide the following information:

Your Full Name

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

1.b. Period of Designation (mm/dd/yyyy)
From ►

Part 2. Information About You (Physician
requesting designation or renewal)

To ►

1.c. USCIS Office that granted the designation

1.c. Middle Name

1.d. Civil Surgeon Identification Number (if known)

Other Information

2.

Date of Birth (mm/dd/yyyy) ►

2.a. Has USCIS ever revoked your designation?

Yes

No

If you checked "Yes," provide the following information:
2.b. Date of Revocation (mm/dd/yyyy) ►

3.a. Have you ever voluntarily terminated your designation?
Yes

No

If you checked "Yes," provide the following information:
3.b. Date of Voluntary Termination
(mm/dd/yyyy) ►
NOTE: If you checked “Yes” to Item Number 2.a. or 3.a.
above, please include a written explanation of the circumstances
surrounding the revocation or voluntary termination, in a
separate letter attached to this application or in Part 10.,
Additional Information.

Form I-910 05/03/13 N

Part 3. Clinical Office Location(s)

Provide the following information about the locations where
you seek to perform immigration medical examinations. If you
seek to perform immigration medical exams in more than one
location, provide the details for each additional location in Part
10., Additional Information.

A. Required Information
You must provide the following information. Failure to provide
this information may result in the denial of your application.
Please refer to Part 2., Section B for more information about
what will be made publicly available.
1.

Name of Clinic/Practice

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Part 3. Clinical Office Locations (continued)

6.

Other

Physical Address of the Clinic/Practice
2.a. Street Number
and Name
2.b. Apt.

Ste.

Flr.

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

)

Fax Number

(
5.

You must be authorized to work in the United States to be
eligible for civil surgeon designation.

Telephone Number

(
4.

Zip Code

)

Part 4. Information About Your Status in the
United States

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-

1.

I am a U.S. citizen or national (Attach proof that you
are a U.S. citizen, such as a copy of a U.S. passport,
birth certificate, or Certificate of Naturalization.)

2.

I am a Legal Permanent Resident (Attach a copy of
your valid Form I-551, Permanent Resident Card. If
you are currently seeking to extend your Form I-551,
attach evidence thereof.)

3.

I am currently present in the United States as a
nonimmigrant (Provide a copy of your Form I-94
Arrival/Departure Record, a copy of your passport or
travel document, and any documents related to your
nonimmigrant status, such as a copy of the petition,
petition approval, and change or extension of status
application.)

-

E-Mail Address (For use by USCIS)

NOTE: USCIS will use the contact information listed above for
all civil surgeon-related communication.

UPDATE USCIS OF ANY CHANGES: Civil surgeons are
responsible for notifying USCIS in writing of any updates to the
contact information provided in this form within 15 days of the
change. Visit the USCIS web site at www.uscis.gov/I-910 for
information on how to submit a change.

B. Optional Information

Providing the following information is optional. Your application
will not be affected if you choose not to provide this information.
If and when feasible, USCIS may provide this information, in
addition to the required information above, as part of the public
civil surgeon list. To submit additional information, please
check the relevant boxes below and provide the requested details:
1.

E-Mail Address (For use by the public)

3.a. Date of Last Arrival (mm/dd/yyyy)►
in the U.S.

3.b. Form I-94 Arrival/ Departure Record Number
(If any)
►
3.c. Passport Number

3.d. Travel Document Number

3.e. Country of Issuance for Passport or Travel Document

2.

Web Site Address (URL)

3.f.
3.

Fees for Medical Examination

Expiration Date for Passport or Travel Document
(mm/dd/yyyy)►

3.g. Current Nonimmigrant Status
4.

Acceptable Means of Payment

5.

Languages Spoken

Form I-910 05/03/13 N

Page 2 of 5

Part 4. Information About Your Status in the
United States (continued)
4.

Other status granted that would allow you to practice
medicine in the United States:

School 1:
1.a. School

1.b. Dates of Attendance (mm/dd/yyyy)
From ►

To ►

1.c. Degree

School 2:
2.a. School

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Part 5. Medical License(s)

You must be licensed to practice medicine in the state or
territory in which you seek to perform immigration medical
examinations to be eligible for civil surgeon designation.
Attach a copy of the medical license(s) listed below.

2.c. Degree

Part 7. Professional Experience

Medical License 1:
1.a. State

OR

U.S. Territory

1.b. Medical License Number

1.c. Date Issued

2.b. Dates of Attendance (mm/dd/yyyy)
To ►
From ►

(mm/dd/yyyy) ►

1.d. Date Expires (mm/dd/yyyy) ►
Medical License 2:
2.a. State

OR

U.S. Territory

You must establish at least 4 years of professional experience to
be eligible for designation. NOTE: Time spent in a post-medical
school training (including internships or residency programs)
cannot be counted toward this experience requirement. Please
attach evidence to verify your professional experience, such
as evaluations, certificates of completion, or letters of
employment verification.
Employer 1:

1.a. Employer

1.b. Dates of Employment (mm/dd/yyyy)
From ►
To ►

1.c. Contact Information

2.b. Medical License Number

Employer 2:
2.c. Date Issued

(mm/dd/yyyy) ►

2.d. Date Expires (mm/dd/yyyy) ►

Part 6. Medical Degree(s)
You must be a Doctor of Medicine (M.D.) or Doctor of
Osteopathy (D.O.) to be eligible for civil surgeon designation.
Attach a copy of the medical degree(s) listed below.

Form I-910 05/03/13 N

2.a. Employer

2.b. Dates of Employment (mm/dd/yyyy)
From ►
To ►
2.c. Contact Information

Page 3 of 5

4.a. Preparer's Daytime Phone Number

Part 8. Signature of Applicant
By signing this form, I accept civil surgeon designation if my
request for designation is granted. Once designated a civil
surgeon, I agree that I will perform the medical examinations
according to the regulations published by Health and Human
Services (HHS) at 42 CFR part 34 and the Technical
Instructions for Civil Surgeons by the Centers for Disease
Control and Prevention (CDC), including periodic updates.
By signing this form, I further agree to comply fully with the
regulations at 8 CFR part 232. I understand that USCIS reserves
the right to revoke civil surgeon designation in certain
circumstances.
I certify, under penalty of perjury under the laws of the United
States of America, that the information provided with this request
is all true and correct. I authorize the release of any information
from my records which USCIS deems necessary in order to
determine my eligibility for designation as a civil surgeon.

(

)

Extension

-

4.b. Preparer's E-mail Address (if any)

5.

Check here if the applicant has authorized you to be a
secondary point of contact for communications
related to civil surgeon designation.

Declaration
I declare that this document was prepared by me at the request of
the applicant and it is based on all information of which I have
knowledge and/or was provided to me by the applicant in
response to the exact questions contained on this form. I have not
knowingly withheld any information.

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1.

Signature of Applicant

2.

Date of Signature (mm/dd/yyyy) ►

6.a. Signature of Preparer

6.b. Date of Signature (mm/dd/yyyy) ►

Part 9. Signature of Person Preparing This
Application, If Other Than Applicant

Attorney or Representative Only: In the event of a Request
for Evidence (RFE), may USCIS contact you by fax or e-mail?
Yes

No

Preparer's Information

Provide the following information concerning the preparer:
1.a. Preparer's Family Name (Last Name)

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

2.

Preparer's Business or Organization Name

3.a. Street Number
and Name
3.b. Apt.

Ste.

Flr.

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

3.e. Zip Code

Form I-910 05/03/13 N

Page 4 of 5

4.a. Page Number

Part 10. Additional Information
If needed, you may use the space below to provide additional
information relevant to this application. Please provide the Page
Number, Part Number, and Item Number to which the
additional information relates.

4.b. Part Number

4.c. Item Number

4.d.

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

2.a. Page Number

2.d.

3.a. Page Number

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2.b. Part Number

2.c. Item Number

5.a. Page Number

5.b. Part Number

5.c. Item Number

6.b. Part Number

6.c. Item Number

5.d.

3.b. Part Number

3.d.

Form I-910 05/03/13 N

3.c. Item Number

6.a. Page Number

6.d.

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