16.
7. Gender FemaleMale
Date of Birth (mm/dd/yyyy)
6.
8.
Married Single Divorced Widowed
Marital Status
OMB No. 1615-0040; Expires 02/28/2018
Department of Homeland Security
U.S. Citizenship and Immigration Services
I-765, Application For
Employment Authorization
Form I-765 02/13/15 Y
Authorization/Extension Valid To
For
USCIS
Use
Only
Fee Stamp
Initial Receipt ResubmittedAction Block
Relocated
Received Sent
Completed
Approved Denied
A#
Application Approved
Authorization/Extension Valid From
Permission to accept employment.
I am applying for: Replacement (of lost employment authorization document).
Renewal of my permission to accept employment (attach a copy of your previous employment authorization document).
(Middle Name)
Other Names Used (include Maiden Name)
2.
(Apt. Number)
U.S. Mailing Address
(ZIP Code)(State)(Town or City)
3.
(Street Number and Name)
Country of Citizenship or Nationality4.
(Country)
Place of Birth
Social Security Number (Include all numbers you have ever
used, if any)
Alien Registration Number (A-Number) or Form I-94 Number
(if any)
10.
Full Name
Have you ever before applied for employment authorization
from USCIS?
No (Proceed to Question 12.)
Yes (Complete the following questions.)
DatesWhich USCIS Office?
Results (Granted or Denied - attach all documentation)
1.
(First Name)(Family Name)
5.
(Town or City) (State/Province)
Current Immigration Status (Visitor, Student, etc.)
15.
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.
( ) )( )(
9.
(c)(3)(C) Eligibility Category. If you entered the eligibility
category (c)(3)(C) in Question 16 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.
17.
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
(c)(26) Eligibility Category. If you entered the eligibility
category (c)(26) in Question 16 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.
18.
Date of Last Entry into the U.S., on or about (mm/dd/yyyy)
12.
Place of Last Entry into the U.S.
13.
Application Denied - Failed to establish:
Economic necessity under
8 CFR 274a.12(c)(14), (18)
and 8 CFR 214.2(f)
Eligibility under
8 CFR 274a.12
(a) or (c)
Applicant is filing under section 274a.12
Subject to the following conditions:
Status at Last Entry (B-2 Visitor, F-1 Student, No Lawful
Status, etc.)
11.
14.
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 Question 16.
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
