Form I-765 01/17/17 N
Page 1 of 2
Authorization/Extension Valid To
Initial Receipt ResubmittedAction Block
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
U.S. Mailing Address
ZIP CodeStateTown or City
Street Number and Name
Country of Citizenship or Nationality
Place of Birth
Town or City State/Province
Application Denied - Failed to establish:
Economic necessity under
8 CFR 274a.12(c)(14), (18)
and 8 CFR 214.2(f)
8 CFR 274a.12
(a) or (c)
Applicant is filing under section 274a.12
Subject to the following conditions:
Alien Registration Number (A-Number) or Form I-94
Number (if any)
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)
Date of Last Entry into the U.S., on or about
Place of Last Entry into the U.S.13.
First NameFamily Name
Other Names Used (include Maiden Name)2.
Middle Name First NameFamily Name
7. Gender FemaleMale
Date of Birth (mm/dd/yyyy)6.
MarriedSingle Divorced Widowed
Current Immigration Status (Visitor, Student, etc.)15.
Status at Last Entry (B-2 Visitor, F-1 Student, No Lawful
16. 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.
( ) )( )(
Application For Employment Authorization
Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0040
Social Security Number (Include all numbers you have
ever used, if any)
START HERE - Type or print in black ink.►