Form 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 10/31/2015

Action Block

Barcode

Initial Receipt (mm/dd/yyyy)
For
Resubmitted (mm/dd/yyyy)
USCIS
Received
Sent
Use
Only

DRAFT

Remarks

CSID Number:
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)

NOT FOR
PRODUCTION

► START HERE - Type or print in black ink.

Part 1. Information About You

1.a. Have you ever been designated as a civil surgeon?
Yes

No

NOTE: If you answered "Yes" to Item Numbers 2.a. or 3.a.
above, include a typed or printed explanation of the
circumstances surrounding the revocation or voluntary
termination in Part 9. Additional Information.

If you answered "Yes," provide the following information.

Your Full Name

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

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

From

To

1.c. U.S. Citizenship and Immigration Services (USCIS)
office that granted the designation

4.c. Middle Name

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

2.a. Has USCIS ever revoked your designation?
Yes

No

Other Names Used
List 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 provide in Part 9.
Additional Information.

04/06/2016
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)

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

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

5.c. Middle Name

No

If you answered "Yes," provide the following information.

Other Information

3.b. Date of Voluntary Termination (mm/dd/yyyy)

6.

Date of Birth (mm/dd/yyyy)

7.

Gender

8.

USCIS Online Account Number (if any)
►

Form I-910 10/22/13 N

Male

Female

Page 1 of 7

Part 2. Clinical Office Locations

7.

Web site Address (URL)

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 the
space provided in Part 9. Additional Information.

8.

Fees for Medical Examination

A. Required Information

DRAFT

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

Name of Clinic/Practice

9.

Acceptable Means of Payment

10.

Accepted Medical Insurance Plans

11.

Languages Spoken

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

NOT FOR
PRODUCTION
Apt.

Ste.

3.

4.

5.

Office Hours

13.

Handicap Accessibility

14.

Other

Flr.

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

12.

2.e. ZIP Code

Telephone Number

Fax Number

Email 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 application 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.

Part 3. Information About Your Status in the
United States
You must be authorized to work in the United States to be
eligible for civil surgeon designation. Select the box that
accurately states how you are authorized to work in the United
States.

04/06/2016
1.

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

2.

I am a Lawful Permanent Resident. (Attach a copy
of your valid Form I-551, Permanent Resident Card.
If you are currently seeking to renew or replace your
Form I-551, attach evidence showing that you are
doing so.)

B. Additional Office Information

Your application will not be affected if you choose not to
provide the following information. USCIS displays this
information on our Web site for people who want to find a civil
surgeon.
6.

Email Address (For use by the public)

Form I-910 10/22/13 N

Page 2 of 7

Part 3. Information About Your Status in the
United States (continued)
3.

I am currently present in the United States as a
nonimmigrant (Attach 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. Also attach a copy of your valid,
unexpired Employment Authorization Document as
proof of your authorization to work in the United
States, if required.)

Part 4. Medical Licenses
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 each medical license listed below. If you
need extra space to complete this section, use the space
provided in Part 9. Additional Information.

DRAFT

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

4.b. Form I-94 Arrival-Departure Record Number (if any)
►

1.a. State

OR

U.S. Territory
1.b. Medical License Number

1.c. Date Issued (mm/dd/yyyy)
1.d. Date Expires (mm/dd/yyyy)

NOT FOR
PRODUCTION

4.c. Passport Number

Medical License 2

4.d. Travel Document Number

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

4.f.

Medical License 1

Expiration Date for Passport or Travel Document

2.a. State

OR

U.S. Territory

2.b. Medical License Number

(mm/dd/yyyy)

4.g. Current Nonimmigrant Status

2.c. Date Issued (mm/dd/yyyy)

2.d. Date Expires (mm/dd/yyyy)

5.

I have been granted another status under U.S.
immigration law that allows me to work and to
practice medicine in the United States:

Part 5. Medical Degrees
You must possess a medical degree as a Doctor of Medicine
(M.D.) or Doctor of Osteopathy (D.O.) to be eligible for civil
surgeon designation. Attach a copy of each medical degree
listed below. If you need extra space to complete this section,
use the space provided in Part 9. Additional Information.

04/06/2016
School 1

1.a. School Name

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

To

1.c. Degree

Form I-910 10/22/13 N

Page 3 of 7

Part 5. Medical Degrees (continued)

2.c. Street Number
and Name

School 2

2.d.

2.a. School Name

Apt.

Ste.

Flr.

2.e. City or Town

DRAFT

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

2.f.

State

2.g. ZIP Code

2.h. Employer's Daytime Telephone Number

Part 6. Professional Experience

Part 7. Applicant's Statement, Contact
Information, Certification, and Signature

You must establish that you have practiced medicine as a
physician (M.D. or D.O.) for at least four years to be eligible for
designation.

NOTE: Read the Penalties section of the Form I-910
Instructions before completing this part. You must file Form
I-910 while in the United States.

NOTE: In calculating whether you meet the requirement of
four years' practice as a physician, DO NOT count your
post graduate medical training in an internship or residency
program. You can, however, count the time you practiced
medicine on the basis of a post-residency fellowship.

Applicant's Statement

NOT FOR
PRODUCTION

Submit evidence to establish your professional experience,
such as evaluations, certificates of completion, business tax
returns and business license (for self-employed physicians),
or letters of employment verification. If you need extra space
to complete this section, use the space provided in Part 9.
Additional Information.
Employer 1

NOTE: If applicable, select the box for Item Number 1.
1.

At my request, the preparer named in Part 8.,

,

prepared this application for me based only upon
information I provided or authorized.

Applicant's Contact Information

2.

Applicant's Daytime Telephone Number

3.

Applicant's Mobile Telephone Number (if any)

4.

Applicant's Email Address (if any)

1.a. Employer's Name

1.b. Dates of Employment (mm/dd/yyyy)
From
To
1.c. Street Number
and Name
1.d.

Apt.

Ste.

1.e. City or Town
1.f.

State

Applicant's Certification

Flr.

By signing this application, I accept civil surgeon designation if
my request for designation is granted. Once designated as 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 34 and the Technical
Instructions for Civil Surgeons by the Centers for Disease
Control and Prevention (CDC), including periodic updates.

04/06/2016

1.g. ZIP Code

1.h. Employer's Daytime Telephone Number

By signing this application, I further agree to comply fully with
the regulations at 8 CFR 232. I understand that USCIS reserves
the right to revoke civil surgeon designation in certain
circumstances.

Employer 2
2.a. Employer's Name

2.b. Dates of Employment (mm/dd/yyyy)
From

Form I-910 10/22/13 N

To

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Part 7. Applicant's Statement, Contact
Information, Certification, and Signature
(continued)
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 of my records that USCIS may need
to determine my eligibility for the designation that I seek.

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

Apt.

Ste.

Flr.

DRAFT

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.

I further 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 laws.
I certify, under penalty of perjury, that I provided or authorized
all of the information in my application, I understand all of the
information contained in, and submitted with, my application,
and that all of this information is complete, true, and correct.

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

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

NOT FOR
PRODUCTION
5.

Preparer's Fax Number

6.

Preparer's Email Address (if any)

Applicant's Signature
5.a. Applicant's Signature

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

7.

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.

Select this box if the preparer may act as a secondary
point of contact for you. USCIS will contact this
preparer if you cannot be reached using the
information in Part 2.

Preparer's Statement
Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Attorney or Representative Only: May USCIS contact you
by fax or email if we need to issue a Request for Evidence
(RFE)?
Yes
No

8.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.

8.b.

I am an attorney or accredited representative and my
representation of the applicant in this case
does not extend beyond the
extends

04/06/2016

Provide the following information about the preparer.

Preparer's Full Name

preparation of this application.
NOTE: If you are an attorney or accredited
representative, you may be obliged to submit a
completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited
Representative, with this application.

1.a. Preparer's Family Name (Last Name)

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

2.

Preparer's Business or Organization Name (if any)

Form I-910 10/22/13 N

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Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
(continued)
Preparer's Certification

DRAFT

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 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
9.a. Preparer's Signature

NOT FOR
PRODUCTION

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

04/06/2016
Form I-910 10/22/13 N

Page 6 of 7

5.a. Page Number

Part 9. 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. Include 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.

5.b. Part Number

5.c. Item Number

5.d.

DRAFT

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

6.a. Page Number

6.b. Part Number

6.c. Item Number

1.c. Middle Name
2.

CSID Number (if any)

NOT FOR
PRODUCTION

3.a. Page Number

3.d.

6.d.

3.b. Part Number

3.c. Item Number

7.a. Page Number

7.b. Part Number

7.c. Item Number

7.d.

4.a. Page Number

4.b. Part Number

4.c. Item Number

4.d.

04/06/2016
Form I-910 10/22/13 N

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