Fillable Form I-910: Application for Civil Surgeon Designation (Visa Pro)

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Form I-910: Application for Civil Surgeon Designation (Visa Pro)

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Page 1 of 6Form I-910 05/29/18
To be completed by an
attorney or accredited
representative (if any).
For
USCIS
Use
Only
Application for Civil Surgeon Designation
Department of Homeland Security
U.S. Citizenship and Immigration Services
START HERE - Type or print in black ink.►
USCIS
Form I-910
OMB No. 1615-0114
Expires 05/31/2020
Action Block
Sent
Received
Initial Receipt Barcode
Resubmitted
Remarks
Part 1. Information About You (The Applicant)
1.a.
Have you ever been designated as a civil surgeon?
If you answered "Yes" to Item Number 1.a., provide the
following information.
U.S. Citizenship and Immigration Services (USCIS)
Office That Granted the Designation
Period of Designation (mm/dd/yyyy)1.b.
1.c.
Civil Surgeon Identification Number (CSID) (if known)
1.d.
From To
Yes No
2.a. Has USCIS ever revoked your designation?
Yes No
Date of Revocation (mm/dd/yyyy)2.b.
If you answered "Yes" to Item Number 2.a., provide the
following information.
3.a.
Have you ever voluntarily terminated your designation?
If you answered "Yes" to Item Number 3.a., provide the
following information.
Yes No
NOTE: If you answered "Yes" to Item Number 2.a. or Item
Number 3.a., above, include a typed or printed explanation of
the circumstances surrounding the revocation or voluntary
termination in Part 9. Additional Information.
Your Full Name
Other Names Used
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c. Middle Name
CSID Number
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)
Middle Name
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c.
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 provided in Part 9.
Additional Information.
Date of Voluntary Termination (mm/dd/yyyy)3.b.
Other Information
Date of Birth (mm/dd/yyyy)6.
7. Gender Male Female
Page 2 of 6Form I-910 05/29/18
Part 1. Information About You (The Applicant)
(continued)
9.
►
A-
Alien Registration Number (A-Number, if any)
USCIS Online Account Number (if any)8.
►
2.c.
2.d.
City or Town
State
2.e.
ZIP Code
Street Number
and Name
2.a.
2.b.
Apt.
Flr.Ste.
Telephone Number3.
Part 2. Clinical Office Locations
You must provide the following information. Failure to provide
this information may result in the denial of your application.
See the Additional Office Information section below for more
information about what will be made publicly available.
Name of Clinic/Practice
1.
Name and Physical Address of the Clinic/Practice
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.
4. Fax Number
Email Address (For Use By USCIS)5.
NOTE: USCIS will use the contact information listed above
for all civil surgeon-related communication.
6. Email Address (For Use By The Public)
7. Website Address (URL)
Fees for Medical Examination
8.
Acceptable Means of Payment9.
Languages Spoken11.
Part 3. Information About Your Status in the
United States
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.)
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. (Select only one box.)
Other14.
Accepted Medical Insurance Plans10.
Office Hours12.
Handicap Accessibility13.
Additional Office Information
Your application will not be affected if you choose not to provide
the following information. USCIS displays this information on
our website for people who want to find a civil surgeon.
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 website at
www.uscis.gov/I-910
for information on how to submit a change.
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.)
2.
(USPS ZIP Code Lookup)
Page 3 of 6Form I-910 05/29/18
Dates of Attendance (mm/dd/yyyy)1.b.
From To
1.c.
Degree
Part 4. Medical Licenses
Date Issued (mm/dd/yyyy)1.c.
Date Expires (mm/dd/yyyy)1.d.
1.a.
State
Medical License 1
U.S. Territory
OR
You must be licensed to practice medicine in the state or U.S.
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.
Medical License 2
Date Issued (mm/dd/yyyy)2.c.
Date Expires (mm/dd/yyyy)2.d.
2.b.
Medical License Number
2.a.
State
OR
U.S. Territory
4.
I have an Employment Authorization Document
(EAD) granted by USCIS that authorizes me to
work in the United States. (Attach a copy of your
valid, unexpired EAD as proof of your authorization
to work in the United States.)
Part 3. Information About Your Status in the
United States (continued)
1.a. School Name
School 1
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.
Passport Number
3.e. Travel Document Number
3.d.
Current Nonimmigrant Status
3.h.
Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
3.g.
3.f. Country of Issuance for Passport or Travel Document
Date of Last Arrival in the U.S. (mm/dd/yyyy)3.b.
3.c.
Form I-94 Arrival-Departure Record Number (if any)
►
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.)
3.a.
School 2
2.c.
Degree
2.a.
School Name
Dates of Attendance (mm/dd/yyyy)2.b.
From To
1.b.
Medical License Number
Page 4 of 6Form I-910 05/29/18
Part 7. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature
NOTE: If applicable, select the box for Item Number 1.
NOTE: Read the Penalties section of the Form I-910
Instructions before completing this section. You must file Form
I-910 while in the United States.
Applicant's Statement
Part 6. Professional Experience
Employer 2
2.b.
2.a. Employer's Name
Dates of Employment (mm/dd/yyyy)
From To
Employer 1
Dates of Employment (mm/dd/yyyy)1.b.
1.a.
Employer's Name
From
To
Employer's Daytime Telephone Number1.h.
1.e. City or Town
1.f. State 1.g. ZIP Code
Street Number
and Name
1.c.
1.d. Apt. Flr.Ste.
Employer's Daytime Telephone Number2.h.
2.e. City or Town
2.f. State 2.g. ZIP Code
Street Number
and Name
2.c.
2.d. Apt. Flr.Ste.
NOTE: In calculating whether you meet the requirement of
four years of 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.
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.
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.
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
Applicant's Daytime Telephone Number2.
Applicant's Email Address (if any)4.
Applicant's Mobile Telephone Number (if any)3.
Applicant's Declaration and Certification
By signing this application, I further agree to comply fully with
the regulations at 8 CFR Part 232. I understand that USCIS
reserves the right to revoke civil surgeon designation in certain
circumstances.
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 Part 34 and the
Technical Instructions for Civil Surgeons by the Centers for
Disease Control and Prevention (CDC).
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 designation as a civil surgeon.
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.
Page 5 of 6Form I-910 05/29/18
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.a.
8.b.
preparation of this application.
I am an attorney or accredited representative and my
representation of the applicant in this case
extends
does not extend beyond the
Preparer's Statement
NOTE: If you are an attorney or accredited
representative, you may need to submit a completed
Form G-28, Notice of Entry of Appearance as
Attorney or Accredited Representative, with this
application.
Preparer's Contact Information
4. Preparer's Daytime Telephone Number
6. Preparer's Email Address (if any)
5. Preparer's Mobile Telephone Number (if any)
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.
7.
Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
1.a. Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)1.b.
Provide the following information about the preparer.
Preparer's Business or Organization Name (if any)2.
Preparer's Full Name
Preparer's Mailing Address
3.h.
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f. Province
Street Number
and Name
3.a.
Country
3.b. Apt. Flr.Ste.
3.g. Postal Code
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
Date of Signature (mm/dd/yyyy)5.b.
Applicant's Signature5.a.
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. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
Preparer's Certification
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.
9.a. Preparer's Signature
9.b. Date of Signature (mm/dd/yyyy)
Preparer's Signature
Page 6 of 6Form I-910 05/29/18
4.a.
Page Number
4.b. Part Number 4.c. Item Number
4.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.
5.a.
Page Number
5.b.
Part Number
5.c.
Item Number
5.d.
3.a.
Page Number
3.b. Part Number
3.c. Item Number
3.d.
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 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.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
CSID Number (if any)2.
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Form I-910: Application for Civil Surgeon Designation (Visa Pro)

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Completed 29 July 2020

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