Approved
OMB No. 1615-0040; Expires 02/28/2013
Remarks
A#
Applicant is filing under §274a.12
Fee StampAction Block
(Date).
Application Approved. Employment Authorized / Extended (Circle One)
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 under 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 (Street Number and Name)
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)
FemaleMale
16. 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.).
Married
Single
Divorced
Widowed
9. Social Security Number (include all numbers you have ever used) (if any)
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 “Who May File Form I-765?” section of the instructions and have identified
the appropriate eligibility category in Question 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.
DateAddress
Signature
Print Name
Relocated
Resubmitted
Completed
Initial Receipt
Received 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 08/15/12 Y
I-765, Application For
Employment Authorization
17. If you entered the eligibility category, (c)(3)(C), in Question 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
) (
(
