Fillable I-905 Application for Authorization to Issue Certification for Health Care

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I-905 Application for Authorization to Issue Certification for Health Care

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The I-905 Application for Authorization to Issue Certification for Health Care form is 3 pages long and contains:

  • 0 signatures
  • 19 check-boxes
  • 48 other fields

Country of origin: US
File type: PDF

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U.S. Citizenship and Immigration Services (USCIS) is an office of the U.S. Branch of Homeland Security (DHS) that oversees the nation's naturalization and migration framework. It is a successor to the Immigration and Naturalization Service (INS), which was disintegrated by the Homeland Security Act of 2002 and supplanted by three segments inside the DHS: USCIS, Immigration and Customs Enforcement (ICE), and Customs and Border Protection (CBP).

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Form I-905 02/11/14 Y
Returned Receipt
Resubmitted
Reloc Sent
Reloc Rec'd
For
USCIS
Use
Only
USCIS
Form I-905
Approved for all requested
occupations.
Partial approval (USCIS must list
approved occupations.)
Action Block
To Be Completed by
Attorney or Representative, if any
Select the box if Form G-28 is
attached to represent the applicant
ATTY State License Number
VOLAG#
START HERE - Please type or print in black ink.
1. Name of Company or Organization
Part 1. Information About the Applicant Filing
This Form
►
Address
ZIP Code
2.e.
State
2.d.
City or Town
3.
5.
Point of Contact
Title
IRS Tax Number
2.c.
Street Number
and Name
2.a.
►(mm/dd/yyyy)
Date the organization was created.6.
Description of your organization.
Describe the process you will use to issue certificates.
Occupations for which you are seeking authorization.
Application for Authorization to Issue Certification
for Health Care Workers
Department of Homeland Security
U.S. Citizenship and Immigration Services
4.b.
4.c.
4.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Flr.Ste.
Apt.
2.b.
Page 1 of 3
Form I-905 02/11/14 Y
Part 1. Information About the Applicant Filing This
Form (continued)
Explain your organization's expertise, knowledge, and
experience in the health care occupations for which you are
seeking authorization.
Describe the procedure you will establish for U.S.
Citizenship and Immigration Services to use to verify the
validity of your certificates.
Explain how your organization meets the standards
described in the instructions sheet.
Part 2. Statement, Certification, Signature, and
Contact Information of the Applicant Filing This
Form
►(mm/dd/yyyy)Date of Signature3.b.
Applicant's Signature3.a.
I certify, under penalty of perjury under the laws of the United
States of America, that the foregoing is true and correct. Copies
of documents submitted are exact photocopies of unaltered
original documents, and I understand that I may be required to
submit original documents to U.S. Citizenship and Immigration
Services (USCIS) at a later date. Furthermore, I authorize the
release of any information from my records that USCIS may
need to determine my eligibility for the benefit that I seek.
I furthermore authorize release of information contained in this
form, in supporting documents, and in my USCIS records, to
other entities and persons where necessary for the
administration of U.S. immigration laws.
I can read and understand English, and have read and
understand each and every question and instruction
on this form, as well as my answer to each question.
1.a.
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
a language in which I am fluent. I understand each
and every question and instruction on this form as
translated to me by my interpreter, and have
provided true and correct responses in the language
indicated above.
The interpreter named in Part 3. has read to me each
and every question and instruction on this form, as
well as my answer to each question, in
1.b.
,
Part 3. Contact Information, Certification, and
Signature of the Interpreter
Interpreter's Family Name (Last Name)1.a.
Interpreter's Full Name
Applicant's Contact Information
Provide the following information concerning the interpreter:
Interpreter's Given Name (First Name)
1.b.
Interpreter's Business or Organization Name (if any)
2.
Interpreter's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
Street Number
and Name
3.a.
2. I have requested the services of and consented to
who is is not
representative, preparing this form for me.
an attorney or accredited
,
Applicant's Daytime Telephone Number4.
Applicant's E-mail Address5.
Flr.Ste.
Apt.
3.b.
Page 2 of 3
Form I-905 02/11/14 Y
NOTE: If you do not completely fill out this form or fail to
submit required documents listed in the instructions, this
application may be denied.
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy) ►
Preparer's Declaration
By my signature, I certify, swear, or affirm, under penalty of
perjury, that I prepared this form on behalf of, at the request of,
and with the express consent of the applicant. I completed the
form based only on responses the applicant provided to me.
After completing the form, I reviewed it and all of the
applicant's responses with the applicant, who agreed with each
and every answer provided for each question on the form and,
when required, supplied additional information to respond to a
question on the form.
I am not an attorney or accredited representative but
have prepared this form on behalf of the applicant
and with the applicant's consent.
I am an attorney or accredited representative and my
representation of the applicant in this case
(choose one) extends does not extend
beyond the preparation of this form.
Preparer's Contact Information
4. Preparer's Daytime Telephone Number
5. Preparer's Fax Number
Preparer's E-mail Address
Preparer's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
Street Number
and Name
3.a.
Preparer's Business or Organization Name2.
Preparer's Given Name (First Name)1.b.
Preparer's Full Name
Provide the following information concerning the preparer:
1.a. Preparer's Family Name (Last Name)
Part 4. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, If Other than the Applicant
Part 3. Contact Information, Certification, and
Signature of the Interpreter (continued)
7.a.
7.b.
6.
Interpreter's Contact Information
4. Interpreter's Daytime Telephone Number
Interpreter's E-mail Address5.
Interpreter Certification
I certify that:
which is the same language provided in Part 2.,
Item Number 1.b.;
I am fluent in English and ,
I have read to this applicant each and every question and
instruction on this form, as well as the answer to each question,
in the language provided in Part 2., Item Number 1.b.; and
Interpreter's Signature
6.a.
►(mm/dd/yyyy)Date of Signature6.b.
The applicant has informed me that he or she understands each
and every instruction and question on the form, as well as the
answer to each question.
Flr.Ste.
Apt.
3.b.
Page 3 of 3
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I-905 Application for Authorization to Issue Certification for Health Care

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Completed 17 November 2019

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