Form I-212 - Application For Permission To Reapply For Admission Into The United States After Deportation Or Removal Page 2
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8If you are seeking consent to reapply in connection with your
Part 1. Information About You (continued)
application to adjust your status to that of a lawful permanent
resident, provide information in Item Numbers 15.a. - 15.c.
Physical Address
15.a. USCIS Receipt Number (if any)
6.a.
Street Number
and Name
6.b.
Apt.
Ste.
Flr.
15.b.
Where did you file your application (for example,
"USCIS Office Name" or "Lockbox")?
6.c.
City or Town
6.d.
State
6.e.
ZIP Code
15.c. Date Filed (mm/dd/yyyy)
6.f.
Province
16.
Are you submitting Form I-601, Application for Waiver
of Grounds of Inadmissibility, along with this application?
6.g. Postal Code
Yes
No
6.h.
Country
If you answered "No," provide the information requested below
about previously filed Forms I-601 (if any):
17.a.
USCIS Receipt Number for Form I-601 (if any)
Other Information About You
7.
U.S. Social Security Number (if any)
17.b.
Where did you file your application (for example,
►
"USCIS Office Name" or "Lockbox")?
8.
Gender
Male
Female
17.c. Date Filed (mm/dd/yyyy)
9.
Date of Birth (mm/dd/yyyy)
10.
City or Town of Birth
Part 2. Reasons You Are Filing Form I-212
If you are inadmissible to the United States for the following
11.
State or Province of Birth (if applicable)
reason, select "Yes" and then select the appropriate boxes. If
you need extra space to complete this section, use the space
provided in Part 8. Additional Information.
12.
Country of Birth
Removal as an Arriving Alien (INA section
212(a)(9)(A)(i))
13.
Country of Citizenship or Nationality
1.a.
I have been removed as an arriving alien in expedited
removal proceedings under INA section 235(b)(1) or I
was removed at the end of proceedings under INA section
If you seek an immigrant or nonimmigrant visa and you are
240 as an arriving alien.
or will file your application for consent to reapply with your
Yes
No
immigrant or nonimmigrant visa application, provide the
I have only been removed once, and my last removal
information requested in Item Numbers 14.a. - 14.b.
1.b.
was less than five years ago.
14.a.
The Department of State (DOS) Consular Case Number
(if available)
1.c.
I have been removed at least two or more times, and
my last removal was less than 20 years ago.
I have been convicted of an aggravated felony in the
1.d.
14.b.
The location of the U.S. Embassy or U.S. Consulate where
United States or abroad, before or after my removal
your immigrant visa application is being or will be made
from the United States. Provide information on your
aggravated felony convictions in Part 8. Additional
City
Information and include the required evidence.
Country
Form I-212 12/23/16 N
Page 2 of 8
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