Notice Of Entry Of Appearance As Attorney Or Accredited Representative (G-28) Page 3
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3OMB No. 1615-0105; Expires 04/30/2012
G-28, Notice of Entry of Appearance
as Attorney or Accredited Representative
Department of Homeland Security
Part 1. Notice of Appearance as Attorney or Accredited Representative
A. This appearance is in regard to immigration matters before:
CBP - List the specific matter in which appearance is entered:
USCIS - List the form number(s):
ICE - List the specific matter in which appearance is entered:
B. I hereby enter my appearance as attorney or accredited representative at the request of:
List Petitioner, Applicant, or Respondent. NOTE: Provide the mailing address of Petitioner, Applicant, or Respondent being represented, and
not the address of the attorney or accredited representative, except when filed under VAWA.
Principal Petitioner, Applicant, or Respondent
A Number or Receipt
Petitioner
Number, if any
Name: Last
First
Middle
Applicant
Respondent
State
Zip Code
Address: Street Number and Street Name
Apt. No.
City
Pursuant to the Privacy Act of 1974 and DHS policy, I hereby consent to the disclosure to the named Attorney or Accredited Representative of any
record pertaining to me that appears in any system of records of USCIS, USCBP, or USICE.
Signature of Petitioner, Applicant, or Respondent
Date
Part 2. Information about Attorney or Accredited Representative
(Check applicable items(s) below)
I am an attorney and a member in good standing of the bar of the highest court(s) of the following State(s), possession(s), territory(ies),
A.
commonwealth(s), or the District of Columbia:
I am not
or
am subject to any order of any court or administrative agency disbarring, suspending, enjoining,
restraining, or otherwise restricting me in the practice of law (If you are subject to any order(s), explain fully on reverse side).
I am an accredited representative of the following qualified non-profit religious, charitable, social service, or similar organization
B.
established in the United States, so recognized by the Department of Justice, Board of Immigration Appeals pursuant to 8 CFR 1292.2.
Provide name of organization and expiration date of accreditation:
.
C.
I am associated with
The attorney or accredited representative of record previously filed Form G-28 in this case, and my appearance as an attorney or
accredited representative is at his or her request (If you check this item, also complete item A or B above in Part 2, whichever is
appropriate).
Part 3. Name and Signature of Attorney or Accredited Representative
I have read and understand the regulations and conditions contained in 8 CFR 103.2 and 292 governing appearances and representation
before the Department of Homeland Security. I declare under penalty of perjury under the laws of the United States that the information I
have provided on this form is true and correct.
Attorney Bar Number(s), if any
Name of Attorney or Accredited Representative
Signature of Attorney or Accredited Representative
Date
Complete Address of Attorney or Organization of Accredited Representative (Street Number and Street Name, Suite No., City, State, Zip Code)
Phone Number (Include area code)
Fax Number, if any (Include area code)
E-Mail Address, if any
Form G-28 (Rev. 04/22/09)N
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