Fillable Federal Forms I-765 - Application For Employment Authorization I- 765_V8.xft

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Federal Forms I-765 - Application For Employment Authorization I- 765_V8.xft

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Country of origin: US
File type: PDF

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Approved
OMB No. 1615-0040; Expires 09/30/11
Remarks
A#
Applicant is filing under §274a.12
Fee Stamp
Action Block
(Date).
until
(Date).
Subject to the following conditions:
Application Denied.
Failed to establish eligibility under 8 CFR 274a.12 (a) or (c).
Failed to establish economic necessity as required in 8 CFR 274a.12(c)(14), (18) and 8 CFR 214.2(f)
Permission to accept employment.
I am applying for:
(Middle)
Date(s)
2. Other Names Used (include Maiden Name)
(Apt. Number)
3. Address in the United States (Number and Street)
12. Date of Last Entry into the U.S. (mm/dd/yyyy)
(ZIP Code)
(State/Country)
(Town or City)
13. Place of Last Entry into the U.S.
4. Country of Citizenship/Nationality
14. Manner of Last Entry (Visitor, Student, etc.)
(Country)
5. Place of Birth (Town or City) (State/Province)
15. Current Immigration Status (Visitor, Student, etc.)
7. Gender
6. Date of Birth (mm/dd/yyyy)
Female
Male
16. Go to Part 2 of the Instructions, Eligibility Categories. In the space below,
place the letter and number of the category you selected from the instructions
(For example, (a)(8), (c)(17)(iii), etc.).
Married
Single
Divorced
Widowed
9. Social Security Number (include all numbers you have ever used) (if any)
Eligibility under 8 CFR 274a.12
10. Alien Registration Number (A-Number) or I-94 Number (if any)
) (
(
Your Certification: I certify, under penalty of perjury under the laws of the United States of America, 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 Instructions in Part 2 and have identified the appropriate eligibility category in
Block 16.
Date
Signature
Signature of Person Preparing Form, If Other Than Above: 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.
Date
Address
Signature
Print Name
Relocated
Resubmitted
Completed
Initial Receipt
Rec'd
Sent
Denied
Returned
) (
)
Which USCIS Office?
Results (Granted or Denied - attach all documentation)
Telephone Number
8. Marital Status
Do not write in this block.
1. Name (Family Name in CAPS) (First)
Certification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Remarks
Replacement (of lost employment authorization document).
Renewal of my permission to accept employment (attach previous employment authorization document).
Form I-765 (Rev. 02/12/10)Y
I-765, Application For
Employment Authorization
17. If you entered the Eligibility Category, (c)(3)(C), in item 16 above, list your
degree, your employer's name as listed in E-Verfy, and your employer's E-
Verify Company Identification Number or a valid E-Verify Client Company
Identification Number in the space below.
11. Have you ever before applied for employment authorization from USCIS?
No
Yes (If "Yes," complete 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
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Federal Forms I-765 - Application For Employment Authorization I- 765_V8.xft

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Completed 6 November 2019

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