I
am applying for:
[]
Permission
to accept employment.
[]
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)
2.Other
Names Used
(include Maiden Name)
3.U.S.
Mailing Address
(Street
Number and Name)
(Apt.
Number)
(Town
or City)
(State)
(ZIP
code)
4.Country
of Citizenship or Nationality
5.Place
of Birth
(Town
or City)
(State/Province)
(Country)
6.Date
of Birth
(mm/dd/yyyy)
7.Gender
Male Female
8.
Marital Status
Married Single Divorced Widowed
9.
Social Security Number
(Include all numbers you have ever used, if any)
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? Dates
Results
(Granted or Denied- attach all documentation)
No
(Proceed to Question
12.)
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.)
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.
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
Employer’s
Name as listed in E-Verify
Employer’s
E-Verify Company Identification Number or a Valid E-Verify Client
Company Identification Number
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.
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.
Applicant’s
Signature
Date
of Signature
(mm/dd/yyyy)
Telephone
Number
Signature
of Person Preparing Form, If Other Than Applicant
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
|
[No
Change]
12.
Date of Your Last Arrival or Entry Into the U.S., On or About
(mm/dd/yyyy)
13.
Place of Your
Last Arrival or Entry
into
the U.S.
[No
Change]
[No
Change]
[No
Change]
[No
Change]
[No
Change]
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-1-797 Notice of Approval for Form I-140.
b.
Have you EVER
been arrested for and/or convicted of any crime? Y/N
NOTE:
If you answered “Yes” to Item
Number 19.b.,
refer to Item
Number 5.,
Item
H.
or Item
I.
in the Who
May File Form I-765
section of the Instructions for information about providing court
dispositions.
|