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I-905fillable (ILW.COM)

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Country of origin: US
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Part 1.
Address
City
Returned
Receipt
Resubmitted
Reloc Sent
Reloc Rec'd
START HERE -
Please type or print in black ink.
Room #
State
IRS Tax #
Phone # of Point of Contact
Title of Point of Contact
Date organization was created.
Description of your organization.
Fill in box if G-28 is attached to
represent the petitioner
VOLAG#
ATTY State License #
Describe the process you will use to issue certificates (If more space is required,
use a separate sheet(s) of paper).
Occupations for which you are seeking authorization.
Explain your organization's expertise, knowledge and experience in the health
care occupations for which you are seeking authorization.
Action Block
Approved for all requested
occupations.
Partial approval (USCIS must list
approved occupations.)
To Be Completed by
Attorney or Representative, if any
For USCIS Use Only
Zip/Postal Code
Company or Organization
Street Number and Name
I-905, Application for Authorization to
Issue Certification for Health Care Workers
OMB No. 1615-0086; Expires 06/30/09
Department of Homeland Security
U.S. Citizenship and Immigration Services
Name of Point of Contact
Form I-905 (Rev. 07/30/07) Y
( )
Print Name
Part 3. Signature of person preparing form, if other than above. (Sign below.)
I declare that I prepared this application at the request of the above person and it is based on all information of which I have
knowledge.
Date
Print Name
Signature
Part 2. Signature.
Read the information on penalties in the instructions before completing this section.
Signature and Title
I certify, under penalty of perjury under the laws of the United States of America, that this application and the evidence submitted with it are all
true and correct. If filing this on behalf of an organization, I certify that I am empowered to do so by that organization. I authorize the release of
any information from my records or from the applicant's organization's records that U.S. Citizenship and Immigration Services needs to determine
eligibility for the benefit I am seeking. If this application is approved, I also agree to provide U.S. Citizenship and Immigration Services with any
information that it requests to determine the organization's eligibility to continue to issue certificates to health care workers.
Date
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.
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. (If more space is required, attach a
separate sheet(s) of paper).
E-Mail Address (If any)
Fax Number (Area Code
and Number)
Daytime Telephone Number (Area Code
and Number)
Firm Name and Address (Street Number and Name;
Suite/Room Number; City/Town; State; Zip Code
Form I-905 (Rev. 07/30/07) Y Page 2
( )
( )
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Completed 9 January 2021

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