Fillable INS-Form-I-765 Application For Employment Authorization

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INS-Form-I-765 Application For Employment Authorization

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The INS-Form-I-765 Application For Employment Authorization form is 2 pages long and contains:

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  • 13 check-boxes
  • 34 other fields

Country of origin: US
File type: PDF

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Form I-765 01/17/17 N
Page 1 of 2
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).
Apt. Number
U.S. Mailing Address
ZIP CodeStateTown or City
3.
Street Number and Name
Country of Citizenship or Nationality
4.
Country
Place of Birth
5.
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)
Eligibility under
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)
10.
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
(mm/dd/yyyy)
12.
Place of Last Entry into the U.S.13.
11.
Middle Name
Full Name
1.
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.
8.
MarriedSingle Divorced Widowed
Marital Status
Current Immigration Status (Visitor, Student, etc.)15.
Status at Last Entry (B-2 Visitor, F-1 Student, No Lawful
Status, etc.)
14.
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
USCIS
Form I-765
OMB No. 1615-0040
Expires 02/28/2018
Social Security Number (Include all numbers you have
ever used, if any)
9.
START HERE - Type or print in black ink.►
183 Gore Creek Street
Vail
CO
81658
Australia
Sydney NSW Australia
12345678
07/20/2017
Los Angeles, CA
SMITH Jane Joan
DOALLY Jane Joan
02/14/1975
K-1
K-1 Visa
C
9
Form I-765 01/17/17 N
Page 2 of 2
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
(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.
19. (c)(35) and (c)(36) Eligibility Category
a. If you entered the eligibility category (c)(35) or (c)(36)
in Question 16 above, please provide the receipt
number of the Form I-140 beneficiary's Form I-797
Notice of Approval for Form I-140.
b. Have you EVER been arrested for and/or convicted of
any crime?
Yes No
NOTE: If you answered "Yes" to Item Numbers 19.b.,
refer to Item Number 5., Item H. or Item I. in the Who
May File Form I-765 section of these Instructions for
information about providing court dispositions.
Employer's E-Verify Company Identification Number or a
Valid E-Verify Client Company Identification Number
(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
09/17/2017
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INS-Form-I-765 Application For Employment Authorization

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Completed 3 July 2020

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