Form I-212 - Application For Permission To Reapply For Admission Into The United States After Deportation Or Removal

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Application for Permission to Reapply for Admission
Into the United States After Deportation or Removal
USCIS
Form I-212
Department of Homeland Security
OMB No. 1615-0018
U.S. Citizenship and Immigration Services
Expires 06/30/2017
For DHS Use Only
Alien Registration Number
Fee Stamp
Action Block
A-
Initial Receipt
Transferred In
Approved
Relocated Returned
Remarks
INA 212(a)(9)(A) for Advance
DHS Office Name/Location
Approval
INA 212(a)(9)(A)
Transferred Out
INA 212(a)(9)(C)
Denied
Start Here. Type or print in black ink.
Part 1. Information About You
Mailing Address
1.
Alien Registration Number (A-Number) (if any)
NOTE: If you are outside the United States, provide a U.S.
mailing address, if available. If a U.S. mailing address is not
A-
available, provide your mailing address abroad.
4.a. In Care Of Name
Your Full Name
2.a. Family Name
(Last Name)
4.b.
Street Number
and Name
2.b.
Given Name
(First Name)
4.c.
Apt.
Ste.
Flr.
2.c.
Middle Name
4.d.
City or Town
Other Names Used
4.e.
State
4.f.
ZIP Code
List all other names you have ever used, including maiden
4.g.
Province
names, aliases, and nicknames. If you need extra space to
complete this section, use the space provided in Part 8.
4.h. Postal Code
Additional Information.
3.a. Family Name
4.i.
Country
(Last Name)
3.b.
Given Name
(First Name)
5.
Is your mailing address the same address where you
currently live (physical address)?
3.c.
Middle Name
Yes
No
If you answered "No" to Item Number 5., provide your
current physical address in Item Numbers 6.a. - 6.h.
Form I-212 12/23/16 N
Page 1 of 8

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