I-212 Application for Permission to Reapply for Admission into

Application for Permission to Reapply for Admission
Into the United States After Deportation or Removal
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-212
OMB No. 1615-0018
Expires 03/31/2024

For DHS Use Only
Alien Registration Number

Fee Stamp

Action Block

AInitial Receipt

Transferred In

Relocated Returned

Approved

Remarks

INA 212(a)(9)(A) for Advance
Approval
INA 212(a)(9)(A)

DHS Office Name/Location

DRAFT
NOT FOR
PRODUCTION
07/12/2023
Transferred Out

INA 212(a)(9)(C)

Denied

To be completed by an
Attorney or Accredited
Representative (if any).

Select this box if
Form G-28 or
Form G-28I is
attached.

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

Part 1. Information About You
1.

Alien Registration Number (A-Number) (if any)
► A-

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

4.c. Middle Name

Your Full Name

Mailing Address

USPS ZIP Code Lookup

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

NOTE: If you are outside the United States, provide a U.S.
mailing address, if available. If a U.S. mailing address is not
available, provide your mailing address abroad.

2.c. Middle Name

5.a. In Care Of Name (if any)

Other Names Used

Provide 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 provided in Part 9.
Additional Information.
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name

5.b. Street Number
and Name
5.c.

Ste.

Flr.

5.d. City or Town
5.e. State

5.f.

ZIP Code

5.g. Province
5.h. Postal Code
5.i.

Form I-212 Edition 03/21/22

Apt.

Country

Page 1 of 10

Part 1. Information About You (continued)
6.

Is your mailing address the same address where you
currently live (physical address)?
Yes
No
If you answered "No" to Item Number 6., provide your
current physical address in Item Numbers 7.a. - 7.f.

Physical Address

Apt.

7.f.

Province

The Department of State (DOS) Consular Case Number
(if available)

DRAFT
NOT FOR
PRODUCTION
06/01/2023
Ste.

17.a. City or Town

Flr.

7.c. City or Town
7.d. State

16.

The Location of the U.S. Embassy or U.S. Consulate Where
Your Application for an Immigrant Visa is Being or Will Be
Made

7.a. Street Number
and Name
7.b.

If you seek an immigrant or nonimmigrant visa and you are or
will file your application for consent to reapply with your
immigrant or nonimmigrant visa application, provide the
information requested in Item Numbers 16. - 17.b.

17.b. Country

7.e. ZIP Code

7.g. Postal Code

If you are seeking consent to reapply in connection with your
application to adjust your status to that of a lawful permanent
resident, provide information in Item Numbers 18.a. - 18.c.

7.h. Country

18.a. USCIS Receipt Number (if any)

Other Information About You
8.

U.S. Social Security Number (if any)
►

9.

18.b. Where did you file your application (for example,
"USCIS Office Name" or "Lockbox")?

18.c. Date Filed (mm/dd/yyyy)

U.S. Online Account Number (if any)
►

10.

Gender

Male

11.

Date of Birth (mm/dd/yyyy)

12.

City or Town of Birth

19.

Are you submitting Form I-601, Application for Waiver
of Grounds of Inadmissibility, along with this application?

Female

Yes

No

If you answered "No," provide the information requested
in Item Numbers 20.a. - 20.c. about previously filed
Forms I-601 (if any):

20.a. USCIS Receipt Number for Form I-601 (if any)

13.

State or Province of Birth (if applicable)
20.b. Where did you file your application (for example,
"USCIS Office Name" or "Lockbox")?

14.

Country of Birth

15.

Country of Citizenship or Nationality

Form I-212 Edition 03/21/22

20.c. Date Filed (mm/dd/yyyy)

Page 2 of 10

Part 2. Reasons You Are Filing Form I-212
If you are inadmissible to the United States for the following
reason, select “Yes” and then select the appropriate boxes. If
you need extra space to complete this section, use the space
provided in Part 9. Additional Information.

Removal as an Arriving Alien (INA Section
212(a)(9)(A)(i))
1.a. I have been removed as an arriving alien in expedited
removal proceedings under INA section 235(b)(1) or I
was removed at the end of proceedings under INA section
240 as an arriving alien.
Yes
No
1.b.

7.a. City or Town

7.b. State

Entry After Unlawful Presence in the Aggregate of
1 Year (INA Section 212(a)(9)(C)(i)(I))

DRAFT
NOT FOR
PRODUCTION
06/01/2023
8.

I have only been removed once, and my last removal
was less than five years ago.

1.c.

I have been removed at least two or more times, and
my last removal was less than 20 years ago.

1.d.

I have been convicted of an aggravated felony in the
United States or abroad, before or after my removal
from the United States. Provide information on your
aggravated felony convictions in Part 9. Additional
Information and include the required evidence.

2.

Location From Where You Were Removed

Date You Were Removed From the United States
(mm/dd/yyyy)

I entered or attempted to enter the United States without
being admitted or paroled, after having been unlawfully
present in the United States on or after April 1, 1997, for a
period of more than one year, in the aggregate.
Yes

No

NOTE: If you answered "Yes" to Item Number 8., list
all the time periods during which you were unlawfully
present in the United States (including any periods in
which you overstayed your lawful status). Begin with
your most recent period of unlawful presence. Also
attach evidence demonstrating that you have remained
outside the United States for 10 years since your last
departure.

Periods of Unlawful Presence
9.a. From (mm/dd/yyyy)

Location From Where You Were Removed
3.

City or Town

9.b. To (mm/dd/yyyy)

10.

4.

State

Date You Departed the United States After Your Period
of Unlawful Presence (mm/dd/yyyy)

Location Where You Departed the United States After Your
Period of Unlawful Presence

Removal as a Deportable Alien (INA Section
212(a)(9)(A)(ii))

5.a. I have been removed as a deportable alien under INA
section 240 or any other provision of the law, or I
departed the United States while an order of removal was
outstanding.
Yes
No
5.b.

I have only been removed once and my removal was
less than 10 years ago.

5.c.

I have been removed two or more times, and my last
removal was less than 20 years ago.

5.d.

I have been convicted of an aggravated felony in the
United States or abroad, before or after my removal
from the United States. Provide information on your
aggravated felony convictions in Part 9. Additional
Information and include the required evidence.

6.

11.a. City or Town

11.b. State

Location Where You Reentered or Attempted to Reenter the
United States
12.a. City or Town

12.b. State

13.

Date You Attempted to Unlawfully Enter or Reenter the
United States After Period of Unlawful Presence
(mm/dd/yyyy)

Date You Were Excluded, Deported, or Removed From
the United States (mm/dd/yyyy)

Form I-212 Edition 03/21/22

Page 3 of 10

Part 2. Reasons You Are Filing Form I-212
(continued)

U.S. Citizen or Lawful Permanent Resident Family
Members (if any)

Entry After Removal (INA Section
212(a)(9)(C)(i)(II))

NOTE: If you need extra space to complete this section, use
the space provided in Part 9. Additional Information.

14.

I entered or attempted to enter the United States without
being admitted or paroled after having been excluded,
deported, or removed.
Yes
No

3.c. Middle Name

DRAFT
NOT FOR
PRODUCTION
06/01/2023

NOTE: If you answered “Yes” to Item Number 14., list
all the dates when you were excluded, deported, or
removed from the United States. If you need extra space
to complete this section, use the space provided in Part 9.
Additional Information.
15.

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

Date You Were Excluded, Deported, or Removed From
the United States (mm/dd/yyyy)

3.d. Relationship

My relative is (Select one):
A lawful permanent resident.
4.a.
4.b.

A U.S. citizen.

Location Where You Reentered or Attempted to Reenter the
United States After Your Exclusion, Deportation, or Removal
16.a. City or Town

Part 4. Biographic Information

1.

16.b. State

Ethnicity (Select only one box)
Hispanic or Latino
Not Hispanic or Latino

17.

Date You Entered or Attempted to Reenter the United
States After Exclusion, Deportation, or Removal
(mm/dd/yyyy)

2.

Race (Select all applicable boxes)
White
Asian

Black or African American

Part 3. Reasons For Your Request For
Permission to Reapply

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

If the Department of Homeland Security (DHS) permits you to
reenter the United States, what immigration status will you seek?
1.a.

Permanent Resident

1.b.

Visitor

1.c.

Student

1.d.

Other (Explain)

2.

Explain Why You Would Like to Reenter the United
States

NOTE: If you need extra space to complete this section,
use the space provided in Part 9. Additional
Information.

Form I-212 Edition 03/21/22

3.

Height

4.

Weight

5.

Eye Color (Select only one box)
Black
Blue

6.

Feet

Inches

Pounds

Brown

Gray

Green

Hazel

Maroon

Pink

Unknown/Other

Hair Color (Select only one box)
Bald (No hair)
Black

Blond

Brown

Gray

Red

Sandy

White

Unknown/Other

Page 4 of 10

Part 5. Additional Information if Filing with
CBP
If you are filing this application with Customs and Border
Protection (CBP), provide the information requested in Item
Numbers 1.a. - 40.c.

Provide physical addresses for everywhere you have lived
during the last ten years, whether inside or outside the United
States. Provide your current address first. If you are unsure of
the exact date, provide the closest approximate date to the best
of your knowledge. If you need extra space to complete this
section, use the space provided in Part 9. Additional
Information.

Ste.

Flr.

Province

1.e. ZIP Code

Name of Employer or Company

Address of Employer or Company

6.b.

Apt.

Ste.

Flr.

6.c. City or Town

1.g. Postal Code
1.h. Country

Employer 1 (current or most recent)

6.a. Street Number
and Name

1.c. City or Town

1.f.

Provide your employment history for the last five years,
whether inside or outside the United States. Provide the most
recent employment first. If you are unsure of the exact
employment date, provide the closest approximate date to the
best of your knowledge. If you need extra space to complete
this section, use the space provided in Part 9. Additional
Information.

5.

1.a. Street Number
and Name

1.d. State

4.b. To (mm/dd/yyyy)

DRAFT
NOT FOR
PRODUCTION
06/01/2023

Physical Address 1 (current address)

Apt.

4.a. From (mm/dd/yyyy)

Employment History

Address History

1.b.

Dates of Residence

6.d. State
6.f.

6.e. ZIP Code

Province

6.g. Postal Code

Dates of Residence

6.h. Country

2.a. From (mm/dd/yyyy)
2.b. To (mm/dd/yyyy)

7.

Your Occupation

Physical Address 2
Dates of Employment

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

Apt.

8.a. From (mm/dd/yyyy)

Ste.

Flr.
8.b. To (mm/dd/yyyy)

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

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Form I-212 Edition 03/21/22

Page 5 of 10

Part 5. Additional Information if Filing with
CBP (continued)

17.

Country of Birth

Employer 2

18.

Current City or Town of Residence (if living)

19.

Current Country of Residence (if living)

9.

Name of Employer or Company

Address of Employer or Company
10.a. Street Number
and Name
10.b.

Apt.

Information About Your Father

DRAFT
NOT FOR
PRODUCTION
06/01/2023
Ste.

Flr.

10.c. City or Town
10.d. State

10.e. ZIP Code

Father's Legal Name
20.a. Family Name
(Last Name)
20.b. Given Name
(First Name)

20.c. Middle Name

10.f. Province

10.g. Postal Code
10.h. Country

11.

Your Occupation

Dates of Employment

Father's Name at Birth (if different than above)
21.a. Family Name
(Last Name)
21.b. Given Name
(First Name)

21.c. Middle Name
22.

Date of Birth (mm/dd/yyyy)

23.

City or Town of Birth

24.

Country of Birth

25.

Current City or Town of Residence (if living)

26.

Current Country of Residence (if living)

12.a. From (mm/dd/yyyy)
12.b. To (mm/dd/yyyy)

Information About Your Parents
Information About Your Mother
Mother's Legal Name
13.a. Family Name
(Last Name)
13.b. Given Name
(First Name)

Information About Your Marital History
27.

13.c. Middle Name

What is your current marital status?
Single, Never Married

Legally Separated

Mother's Name at Birth (if different than above)

Married

Marriage Annulled

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

Divorced

Other

14.c. Middle Name
15.

Date of Birth (mm/dd/yyyy)

16.

City or Town of Birth

Form I-212 Edition 03/21/22

Widowed
28.

How many times have you been married (including
annulled marriages and marriages to the same person)?

Page 6 of 10

Part 5. Additional Information if Filing with
CBP (continued)
Information About Your Current Marriage
(including if you are legally separated)
If you are currently married, provide the following information
about your current spouse.
Current Spouse's Legal Name

Information About Prior Marriages (if any)
If you have been married before, whether in the United States or
in any other country, provide the following information about
your prior spouse. If you have had more than one previous
marriage, use the space provided in Part 9. Additional
Information to provide the information below.
Prior Spouse's Legal Name (provide family name before
marriage)
35.a. Family Name
(Last Name)
35.b. Given Name
(First Name)

DRAFT
NOT FOR
PRODUCTION
06/01/2023

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

29.c. Middle Name
30.

A-Number (if any) ► A-

31.

Current Spouse's Date of Birth (mm/dd/yyyy)

32.

Date of Marriage to Current Spouse (mm/dd/yyyy)

35.c. Middle Name
36.

Prior Spouse's Date of Birth (mm/dd/yyyy)

37.

Date of Marriage to Prior Spouse (mm/dd/yyyy)

Place of Marriage to Prior Spouse

38.a. City or Town

Current Spouse's Place of Birth
33.a. City or Town

33.b. State or Province

33.c. Country

38.b. State or Province

38.c. Country

39.

Date Marriage with Prior Spouse Legally Ended
(mm/dd/yyyy)

Place of Marriage to Current Spouse
34.a. City or Town

34.b. State or Province

34.c. Country

Form I-212 Edition 03/21/22

Place Where Marriage with Prior Spouse Legally Ended
40.a. City or Town

40.b. State or Province

40.c. Country

Page 7 of 10

Part 6. Applicant's Contact Information,
Certification, and Signature

Interpreter's Contact Information
3.

Interpreter's Daytime Telephone Number

4.

Interpreter's Mobile Telephone Number (if any)

5.

Interpreter's Email Address (if any)

Applicant's Contact Information
Provide your daytime telephone number, mobile telephone
number (if any), and email address (if any).
1.

Applicant's Daytime Telephone Number

2.

Applicant's Mobile Telephone Number (if any)

DRAFT
NOT FOR
PRODUCTION
06/01/2023

Interpreter's Certification and Signature

3.

Applicant's Email Address (if any)

Applicant's Certification and Signature

I certify, under penalty of perjury, that I provided or authorized
all of the responses and information contained in and submitted
with my application, I read and understand or, if interpreted to
me in a language in which I am fluent by the interpreter listed in
Part 7., understood, all of the responses and information
contained in, and submitted with, my application, and that all of
the responses and the information are complete, true, and
correct. Furthermore, I authorize the release of any information
from any and all of my records that USCIS may need to
determine my eligibility for an immigration request and to other
entities and persons where necessary for the administration and
enforcement of U.S. immigration law.
4.

►

Applicant's Signature

I certify, under penalty of perjury, that I am fluent in English
, and I have interpreted
and
every question on the application and Instructions and
interpreted the applicant's answers to the questions in that
language, and the applicant informed me that they understood
every instruction, question, and answer on the application.
6.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Preparer's Full Name

1.

Preparer's Family Name (Last Name)

Date of Signature (mm/dd/yyyy)

Preparer's Given Name (First Name)

Part 7. Interpreter's Contact Information,
Certification, and Signature

2.

Preparer's Business or Organization Name

Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

Preparer's Contact Information
3.

Preparer's Daytime Telephone Number

4.

Preparer's Mobile Telephone Number (if any)

5.

Preparer's Email Address (if any)

Interpreter's Given Name (First Name)

2.

Interpreter's Business or Organization Name

Form I-212 Edition 03/21/22

Page 8 of 10

Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
(continued)
Preparer's Certification and Signature
I certify, under penalty of perjury, that I prepared this
application for the applicant at their request and with express
consent and that all of the responses and information contained
in and submitted with the application are complete, true, and
correct and reflects only information provided by the applicant.
The applicant reviewed the responses and information and
informed me that they understand the responses and information
in or submitted with the application.
6.

DRAFT
NOT FOR
PRODUCTION
06/01/2023

Preparer's Signature

Date of Signature (mm/dd/yyyy)

Form I-212 Edition 03/21/22

Page 9 of 10

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. Type or print your name and A-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
NOT FOR
PRODUCTION
06/01/2023

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

1.c. Middle Name
2.

A-Number (if any) ► A-

3.a. Page Number

3.d.

4.a. Page Number

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

4.b. Part Number

4.d.

Form I-212 Edition 03/21/22

4.c. Item Number

7.a. Page Number

7.d.

Page 10 of 10