Form I-765 07/17/17 N
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Alien Registration Number (A-Number) or Form I-94
Number (if any)
14.
Have you ever before applied for employment
authorization from USCIS?
No (Proceed to Item Number 16.)
Yes (Complete the following questions.)
DatesWhich USCIS Office?
Results (Granted or Denied - attach all documentation)
Date of Your Last Arrival or Entry Into the U.S., On or
About (mm/dd/yyyy)
16.
Place of Your Last Arrival or Entry Into the U.S.17.
15.
Current Immigration Status (Visitor, Student, etc.)
19.
Status at Last Entry (B-2 Visitor, F-1 Student, No Lawful
Status, etc.)
18.
20. 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.
( ) )( )(
Mother's Name (Provide your mother's birth name.)
13.a. Family Name
(Last Name)
13.b. Given Name
(First Name)
Employer's E-Verify Company Identification Number or a
Valid E-Verify Client Company Identification Number
(c)(3)(C) Eligibility Category. If you entered the eligibility
category (c)(3)(C) in Item Number 20. 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.
21.
Degree
Employer's Name as listed in E-Verify
(c)(26) Eligibility Category. If you entered the eligibility
category (c)(26) in Item Number 20. 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.
22.
23. (c)(35) and (c)(36) Eligibility Category
a. If you entered the eligibility category (c)(35) or (c)(36)
in Item Number 20. above, please provide the receipt
number of the Form I-140 beneficiary's Form I-797
Notice of Approval for Form I-140.
b. Have you EVER been arrested for and/or convicted of
any crime?
Yes No
NOTE: If you answered "Yes" to Item Number 23.b.,
refer to Item Number 5., Item H. or Item I. in the Who
May File Form I-765 section of these Instructions for
information about providing court dispositions.
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 Item
Number 20.
Applicant's Signature
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 of Signature (mm/dd/yyyy)
Telephone Number
Certification
Signature of Person Preparing Form, If Other Than
Applicant
Preparer's Signature
Date of Signature (mm/dd/yyyy)
Printed Name
Address
