Fillable Form I-212: Application For Permission To Reapply For (Visa Pro)

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Form I-212: Application For Permission To Reapply For (Visa Pro)

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Form I-212 04/27/18 Page 1 of 11
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 04/20/2020
For DHS Use Only
Transferred InInitial Receipt
Remarks
Action Block
Approved
INA 212(a)(9)(A) for Advance
Approval
INA 212(a)(9)(A)
INA 212(a)(9)(C)
Relocated Returned
Denied
Transferred Out
DHS Office Name/Location
Fee Stamp
A-
Alien Registration Number
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)
To be completed by an
Attorney or Accredited
Representative (if any).
START HERE - Type or print in black ink.►
Part 1. Information About You
Alien Registration Number (A-Number) (if any)
►
A-
1.
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Middle Name
Your Full Name
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name
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.
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c. Middle Name
Mailing Address USPS ZIP Code Lookup
5.b.
Street Number
and Name
5.c. Apt. Ste. Flr.
5.d. City or Town
5.e.
State
5.f.
ZIP Code
5.g. Province
5.h. Postal Code
5.i. Country
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.
In Care Of Name (if any)5.a.
Form I-212 04/27/18 Page 2 of 11
Part 1. Information About You (continued)
Is your mailing address the same address where you
currently live (physical address)?
Yes No
6.
If you answered "No" to Item Number 6., provide your
current physical address in Item Numbers 7.a. - 7.f.
7.a.
Street Number
and Name
Apt. Ste. Flr.
City or Town
State ZIP Code
Province
Postal Code
7.h. Country
7.b.
7.c.
7.d.
7.f.
7.g.
7.e.
Physical Address
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.
16. The Department of State (DOS) Consular Case Number
(if available)
The Location of the U.S. Embassy or U.S. Consulate Where
Your Application for an Immigrant Visa is Being or Will Be
Made
City or Town
Country
17.a.
17.b.
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.
USCIS Receipt Number (if any)
18.a.
Other Information About You
U.S. Social Security Number (if any)
►
8.
U.S. Online Account Number (if any)
►
9.
10. FemaleGender Male
Date of Birth (mm/dd/yyyy)11.
12. City or Town of Birth
State or Province of Birth (if applicable)13.
Country of Birth14.
Country of Citizenship or Nationality15.
Where did you file your application (for example,
"USCIS Office Name" or "Lockbox")?
18.b.
Date Filed (mm/dd/yyyy)18.c.
Are you submitting Form I-601, Application for Waiver
of Grounds of Inadmissibility, along with this application?
Yes No
19.
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)
Where did you file your application (for example,
"USCIS Office Name" or "Lockbox")?
20.b.
Date Filed (mm/dd/yyyy)20.c.
Form I-212 04/27/18 Page 3 of 11
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))
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.
1.a.
I have only been removed once, and my last removal
was less than five years ago.
1.b.
I have been removed at least two or more times, and
my last removal was less than 20 years ago.
1.c.
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.
1.d.
Yes No
City or Town
Date You Were Removed From the United States
2.
(mm/dd/yyyy)
Location From Where You Were Removed
State
3.
4.
Removal as a Deportable Alien (INA Section
212(a)(9)(A)(ii))
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.
I have only been removed once and my removal was
less than 10 years ago.
5.b.
5.a.
I have been removed two or more times, and my last
removal was less than 20 years ago.
5.c.
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.
5.d.
Yes No
City or Town
State
7.a.
7.b.
Location From Where You Were Removed
Entry After Unlawful Presence in the Aggregate of
1 Year (INA Section 212(a)(9)(C)(i)(I))
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
8.
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
From (mm/dd/yyyy)
9.a.
To (mm/dd/yyyy)9.b.
Date You Departed the United States After Your Period
of Unlawful Presence (mm/dd/yyyy)
10.
Location Where You Departed the United States After Your
Period of Unlawful Presence
City or Town
State
11.a.
11.b.
Location Where You Reentered or Attempted to Reenter the
United States
City or Town
State
12.a.
12.b.
6.
Date You Were Excluded, Deported, or Removed From
the United States (mm/dd/yyyy)
Date You Attempted to Unlawfully Enter or Reenter the
United States After Period of Unlawful Presence
(mm/dd/yyyy)
13.
Form I-212 04/27/18 Page 4 of 11
Entry After Removal (INA Section
212(a)(9)(C)(i)(II))
Part 2. Reasons You Are Filing Form I-212
(continued)
I entered or attempted to enter the United States without
being admitted or paroled after having been excluded,
deported, or removed.
Yes No
14.
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.
Date You Were Excluded, Deported, or Removed From
the United States (mm/dd/yyyy)
15.
Location Where You Reentered or Attempted to Reenter the
United States After Your Exclusion, Deportation, or Removal
City or Town
State
16.a.
16.b.
Date You Entered or Attempted to Reenter the United
States After Exclusion, Deportation, or Removal
(mm/dd/yyyy)
17.
Part 3. Reasons For Your Request For
Permission to Reapply
If the Department of Homeland Security (DHS) permits you to
reenter the United States, what immigration status will you seek?
1.a. Permanent Resident
Visitor
Student
Other (Explain)
1.b.
1.c.
1.d.
Explain Why You Would Like to Reenter the United
States
2.
NOTE: If you need extra space to complete this section,
use the space provided in Part 9. Additional
Information.
U.S. Citizen or Lawful Permanent Resident Family
Members (if any)
NOTE: 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
3.d. Relationship
A lawful permanent resident.
A U.S. citizen.
My relative is (Select one):
4.a.
4.b.
Part 4. Biographic Information
Ethnicity (Select only one box)1.
Not Hispanic or Latino
Hispanic or Latino
Race (Select all applicable boxes)
2.
Height3. Feet Inches
White
Asian
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Weight
4. Pounds
Blue
Eye Color (Select only one box)5.
Black
Brown
Gray
Green
Hazel
Maroon
Pink Unknown/Other
Hair Color (Select only one box)6.
Bald (No hair)
Black Blond
Brown
Gray
Red
Sandy
White
Unknown/Other
Form I-212 04/27/18 Page 5 of 11
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.
Physical Address 1 (current address)
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.
Address History
1.a. Street Number
and Name
Apt. Ste. Flr.
City or Town
State ZIP Code
Province
Postal Code
1.h. Country
1.b.
1.c.
1.d.
1.f.
1.g.
1.e.
Dates of Residence
From (mm/dd/yyyy)2.a.
To (mm/dd/yyyy)2.b.
Physical Address 2
3.a. Street Number
and Name
Apt. Ste. Flr.
City or Town
State ZIP Code
Province
Postal Code
3.h. Country
3.b.
3.c.
3.d.
3.f.
3.g.
3.e.
Dates of Residence
From (mm/dd/yyyy)
4.a.
To (mm/dd/yyyy)4.b.
Employment History
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.
Employer 1 (current or most recent)
5.
Name of Employer or Company
Address of Employer or Company
6.b.
Street Number
and Name
6.c.
6.d.
City or Town
6.f.
State
6.e.
ZIP Code
6.g.
Province
6.h.
Postal Code
Country
6.a.
Dates of Employment
From (mm/dd/yyyy)
8.a.
To (mm/dd/yyyy)8.b.
Apt. Ste. Flr.
7. Your Occupation
Form I-212 04/27/18 Page 6 of 11
Employer 2
9.
Name of Employer or Company
Address of Employer or Company
10.b.
Street Number
and Name
10.c.
10.d.
City or Town
10.f.
State
10.e.
ZIP Code
10.g.
Province
10.h.
Postal Code
Country
10.a.
11. Your Occupation
Dates of Employment
From (mm/dd/yyyy)
12.a.
To (mm/dd/yyyy)12.b.
Part 5. Additional Information if Filing with
CBP (continued)
Apt. Ste. Flr.
Mother's Legal Name
13.a. Family Name
(Last Name)
13.b. Given Name
(First Name)
13.c. Middle Name
Information About Your Parents
Mother's Name at Birth (if different than above)
14.a. Family Name
(Last Name)
14.b. Given Name
(First Name)
14.c. Middle Name
Date of Birth (mm/dd/yyyy)15.
Country of Birth17.
18. Current City or Town of Residence (if living)
Current Country of Residence (if living)19.
Father's Legal Name
20.a. Family Name
(Last Name)
20.b. Given Name
(First Name)
20.c. Middle Name
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
Date of Birth (mm/dd/yyyy)22.
23. City or Town of Birth
Information About Your Mother
Information About Your Father
Country of Birth24.
25. Current City or Town of Residence (if living)
Current Country of Residence (if living)26.
Information About Your Marital History
What is your current marital status?27.
Single, Never Married
Divorced
Widowed
Legally Separated
Marriage Annulled
Other
28. How many times have you been married (including
annulled marriages and marriages to the same person)?
Married
16. City or Town of Birth
Form I-212 04/27/18 Page 7 of 11
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
29.a. Family Name
(Last Name)
29.b. Given Name
(First Name)
29.c. Middle Name
A-Number (if any) ►
A-
30.
Current Spouse's Date of Birth (mm/dd/yyyy)
31.
32.
Date of Marriage to Current Spouse (mm/dd/yyyy)
Current Spouse's Place of Birth
City or Town
Country
State or Province
33.a.
33.b.
33.c.
Part 5. Additional Information if Filing with
CBP (continued)
Place of Marriage to Current Spouse
City or Town
Country
State or Province
34.a.
34.b.
34.c.
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)
35.c. Middle Name
Prior Spouse's Date of Birth (mm/dd/yyyy)
36.
Date of Marriage to Prior Spouse (mm/dd/yyyy)37.
Place of Marriage to Prior Spouse
City or Town
Country
State or Province
38.a.
38.b.
38.c.
Date Marriage with Prior Spouse Legally Ended
39.
(mm/dd/yyyy)
Place Where Marriage with Prior Spouse Legally Ended
City or Town
Country
State or Province
40.a.
40.b.
40.c.
Form I-212 04/27/18 Page 8 of 11
Part 6. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature
NOTE: Read the Penalties section of the Form I-212
Instructions before completing this part.
Applicant's Statement
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
1.a.
I can read and understand English, and I have read
and understand every question and instruction on this
application and my answer to every question.
1.b.
The interpreter named in Part 7. read to me every
question and instruction on this application and my
answer to every question in
a language in which I am fluent, and I understood
everything.
2.
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
3. Applicant's Daytime Telephone Number
4. Applicant's Mobile Telephone Number (if any)
5. Applicant's Email Address (if any)
Applicant's Declaration and Certification
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 and all of my records that USCIS
may need to determine my eligibility for the immigration
benefit that I seek.
I furthermore 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 law.
I understand that USCIS may require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, if I am required to provide
biometrics, I will be required to sign an oath reaffirming that:
1) I reviewed and understood all of the information
contained in, and submitted with, my application; and
2) All of this information was complete, true, and correct
at the time of filing.
I certify, under penalty of perjury, that all of the information in
my application and any document submitted with it were
provided or authorized by me, that I reviewed and understand
all of the information contained in, and submitted with, my
application and that all of this information is complete, true, and
correct.
Applicant's Signature
6.a. Applicant's Signature
6.b. Date of Signature (mm/dd/yyyy)
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.
Part 7. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter.
Interpreter's Full Name
Interpreter's Business or Organization Name (if any)
2.
Interpreter's Given Name (First Name)1.b.
Interpreter's Family Name (Last Name)1.a.
►
Form I-212 04/27/18 Page 9 of 11
Part 7. Interpreter's Contact Information,
Certification, and Signature (continued)
Interpreter's Contact Information
4. Interpreter's Daytime Telephone Number
5. Interpreter's Mobile Telephone Number (if any)
6. Interpreter's Email Address (if any)
Interpreter's Mailing Address
3.a.
Street Number
and Name
3.b.
3.c. City or Town
3.d.
State
3.e.
ZIP Code
3.f. Province
3.g. Postal Code
3.h. Country
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and ,
which is the same language specified in Part 6., Item Number
1.b., and I have read to this applicant in the identified language
every question and instruction on this application and his or her
answer to every question. The applicant informed me that he or
she understands every instruction, question, and answer on the
application, including the Applicant's Declaration and
Certification, and has verified the accuracy of every answer.
Interpreter's Signature
7.a. Interpreter's Signature
7.b. Date of Signature (mm/dd/yyyy)
Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Provide the following information about the preparer.
Preparer's Full Name
Preparer's Business or Organization Name (if any)
2.
Preparer's Given Name (First Name)1.b.
Preparer's Family Name (Last Name)1.a.
Preparer's Mailing Address
3.a.
Street Number
and Name
3.b.
3.c. City or Town
3.d.
State
3.e.
ZIP Code
3.f. Province
3.g. Postal Code
3.h. Country
Preparer's Contact Information
4. Preparer's Daytime Telephone Number
5. Preparer's Mobile Telephone Number (if any)
6. Preparer's Email Address (if any)
Apt. Ste. Flr.
Apt. Ste. Flr.
Form I-212 04/27/18 Page 10 of 11
Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
(continued)
Preparer's Statement
7.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.
7.b.
I am an attorney or accredited representative and my
representation of the applicant in this case
extends does not extend beyond the
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,
or Form G-28I, Notice of Entry of Appearance as Attorney In
Matters Outside the Geographical Confines of the United States,
with this application.
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 Declaration and 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 Certification
Preparer's Signature
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
Form I-212 04/27/18 Page 11 of 11
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.
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.b. Part Number 3.c. Item Number
3.d.
4.a. Page Number 4.b. Part Number 4.c. Item Number
4.d.
5.a. Page Number 5.b. Part Number 5.c. Item Number
5.d.
6.a. Page Number
6.b. Part Number 6.c. Item Number
6.d.
7.a. Page Number
7.b. Part Number 7.c. Item Number
7.d.
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Form I-212: Application For Permission To Reapply For (Visa Pro)

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Completed 29 July 2020

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