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
Action Block

Fee Stamp

For
USCIS
Use
Only

OMB No. 1615-0040
Expires 02/28/2018

Initial Receipt

Draft
Not for
Production
11/01/2016

Resubmitted

Relocated

Received

Application Denied - Failed to establish:

Application Approved

Eligibility under
8 CFR 274a.12
(a) or (c)

Authorization/Extension Valid From
Authorization/Extension Valid To
Subject to the following conditions:

Economic necessity under
8 CFR 274a.12(c)(14), (18)
and 8 CFR 214.2(f)

Sent

Completed

Approved

Denied

A#

Applicant is filing under section 274a.12

► START HERE - Type or print in black ink.

9.

I am applying for:

Permission to accept employment.

Social Security Number (Include all numbers you have
ever used, if any)

Replacement (of lost employment authorization document).
Renewal of my permission to accept employment (attach a
copy of your previous employment authorization
document).
1.

Full Name
Family Name

First Name

Middle Name

10. Alien Registration Number (A-Number) or Form I-94
Number (if any)

11. Have you ever before applied for employment
authorization from USCIS?
Yes (Complete the following questions.)
Which USCIS Office?

2.

Dates

Other Names Used (include Maiden Name)
Family Name

First Name

Middle Name

Results (Granted or Denied - attach all documentation)

No (Proceed to Question 12.)
3.

U.S. Mailing Address
Street Number and Name

Apt. Number

Town or City

State

4.

Country of Citizenship or Nationality

5.

Place of Birth
Town or City

State/Province

6.

Date of Birth (mm/dd/yyyy)

7.

Gender

8.

Marital Status

Male

ZIP Code

12. Date of Last Entry into the U.S., on or about
(mm/dd/yyyy)

13. Place of Last Entry into the U.S.

14. Status at Last Entry (B-2 Visitor, F-1 Student, No Lawful
Status, etc.)

Country

15. Current Immigration Status (Visitor, Student, etc.)

16. Eligibility Category. Go to the "Who May File Form
I-765?" section of the Instructions. In the space below, place
the letter and number of the eligibility category you selected
from the instructions. For example, (a)(8), (c)(17)(iii), etc.

Female

(
Single

Married

Form I-765 02/13/15 N

Divorced

)(

)(

)

Widowed
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17. (c)(3)(C) Eligibility Category. If you entered the
eligibility category (c)(3)(C) in Question 16 above, list
your degree, your employer's name as listed in E-Verify,
and your employer's E-Verify Company Identification
Number or a valid E-Verify Client Company Identification
Number in the space below.
Degree

Certification
I certify, under penalty of perjury, that the foregoing is true and
correct. Furthermore, I authorize the release of any information
that U.S. Citizenship and Immigration Services needs to
determine eligibility for the benefit I am seeking. I have read
the “Who May File Form I-765?” section of the instructions
and have identified the appropriate eligibility category in
Question 16.

Draft
Not for
Production
11/01/2016

Employer's Name as listed in E-Verify

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

Applicant's Signature

Date of Signature (mm/dd/yyyy)

18. (c)(26) Eligibility Category. If you entered the eligibility
category (c)(26) in Question 16 above, please provide the
receipt number of your H-1B principal spouse's most recent
Form I-797 Notice of Approval for Form I-129.

Telephone Number

Signature of Person Preparing Form, If Other Than
Applicant

19. (c)(35) and (c)(36) Eligibility Category
a.

If you entered the eligibility category (c)(35) or (c)(36)
in Question 16 above, please provide the receipt
number of the Form I-140 beneficiary's Form I-797
Notice of Approval for Form I-140.

b. Have you EVER been arrested for and/or convicted of
any crime?
Yes
No
NOTE: If you answered "Yes" to Item Numbers 19.b.,
refer to Item Number 5., Item H. or Item I. in the Who
May File Form I-765 section of these Instructions for
information about providing court dispositions.

Form I-765 02/13/15 N

I declare that this document was prepared by me at the request
of the applicant and is based on all information of which I have
any knowledge.
Preparer's Signature

Date of Signature (mm/dd/yyyy)
Printed Name

Address

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