Fillable PrePosti-765 Application For Employment Authorization

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PrePosti-765 Application For Employment Authorization

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The PrePosti-765 Application For Employment Authorization form is 2 pages long and contains:

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  • 19 check-boxes
  • 49 other fields

Country of origin: US
File type: PDF

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Form I-765 07/17/17 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:
Middle Name
Full Name
1.
First NameFamily Name
Other Names Used (include Maiden Name)2.
Middle Name First NameFamily Name
Date of Birth (mm/dd/yyyy)
6.
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
START HERE - Type or print in black ink.►
Has the Social Security Administration (SSA) ever
officially issued a Social Security card to you?
NoYes
9.a.
NOTE: If you answered “Yes” to Item Number 9.a.,
provide the information requested in Item Number 9.b.
Provide your Social Security number (SSN) (if known)9.b.
►
Do you want the SSA to issue you a Social Security card?
(You must also answer “Yes” to Item Number 11.,
Consent for Disclosure, to receive a card.)
10.
NoYes
NOTE: If you answered “No” to Item Number 10., skip
to Item Number 14. If you answered “Yes” to Item
Number 10., you must also answer “Yes” to Item
Number 11.
Consent for Disclosure: I authorize disclosure of
information from this application to the SSA as required
for the purpose of assigning me an SSN and issuing me a
Social Security card.
11.
NoYes
NOTE: If you answered “Yes” to Item Numbers 10. - 11.,
provide the information requested in Item Numbers 12.a. - 13.b.
Father's Name
12.a. Family Name
(Last Name)
12.b. Given Name
(First Name)
7. Gender FemaleMale
8.
MarriedSingle Divorced Widowed
Marital Status
Form I-765 07/17/17 N
Page 2 of 2
Alien Registration Number (A-Number) or Form I-94
Number (if any)
14.
Have you ever before applied for employment
authorization from USCIS?
No (Proceed to Item Number 16.)
Yes (Complete the following questions.)
DatesWhich USCIS Office?
Results (Granted or Denied - attach all documentation)
Date of Your Last Arrival or Entry Into the U.S., On or
About (mm/dd/yyyy)
16.
Place of Your Last Arrival or Entry Into the U.S.17.
15.
Current Immigration Status (Visitor, Student, etc.)
19.
Status at Last Entry (B-2 Visitor, F-1 Student, No Lawful
Status, etc.)
18.
20. 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.
( ) )( )(
Mother's Name (Provide your mother's birth name.)
13.a. Family Name
(Last Name)
13.b. Given Name
(First Name)
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 Item Number 20. 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.
21.
Degree
Employer's Name as listed in E-Verify
(c)(26) Eligibility Category. If you entered the eligibility
category (c)(26) in Item Number 20. 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.
22.
23. (c)(35) and (c)(36) Eligibility Category
a. If you entered the eligibility category (c)(35) or (c)(36)
in Item Number 20. 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 Number 23.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.
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 Item
Number 20.
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
F1 Student
F1 Student
C
3
B
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PrePosti-765 Application For Employment Authorization

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Completed 8 February 2020

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