Form I-212 - Application For Permission To Reapply For Admission Into The United States After Deportation Or Removal Page 4
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85.
Eye Color (Select only one box)
Part 3. Reasons For Your Request For
Permission to Reapply
Black
Blue
Brown
Gray
Green
Hazel
If the Department of Homeland Security (DHS) permits you to
reenter the United States, what immigration status will you seek?
Maroon
Pink
Unknown/Other
6.
Hair Color (Select only one box)
1.a.
Permanent Resident
Bald (No hair)
Black
Blond
1.b.
Visitor
Brown
Gray
Red
1.c.
Student
Sandy
White
Unknown/
1.d.
Other (Explain)
Other
Part 5. Applicant's Statement, Contact
Explain why you would like to reenter the United States
2.
Information, Acknowledgement of Appointment
at USCIS Application Support Center,
NOTE: If you need extra space to complete this section, use
Certification, and Signature
the space provided in Part 8. Additional Information.
NOTE: Read the information on penalties in the Penalties
section of the Form I-212 Instructions before completing this
U.S. Citizen or Lawful Permanent Resident Family
part.
Members (if any)
Applicant's Statement
NOTE: If you need extra space to complete this section, use
the space provided in Part 8. Additional Information.
NOTE: Select the box for either Item Number 1.a. or 1.b. If
3.a. Family Name
applicable, select the box for Item Number 2.
(Last Name)
I can read and understand English, and have read and
1.a.
3.b.
Given Name
understand every question and instruction on this
(First Name)
application, as well as my answer to every question.
3.c.
Middle Name
I have read and understand the Acknowledgement of
Appointment at USCIS Application Support
3.d. Relationship
Center.
The interpreter named in Part 6. has read to me every
1.b.
question and instruction on this application, as well as
My relative is (Select one):
my answer to every question, in
4.a.
A lawful permanent resident.
,
4.b.
A U.S. citizen.
a language in which I am fluent. I understand every
question and instruction on this application as
translated to me by my interpreter, and have provided
Part 4. Biographic Information
complete, true, and correct responses in the language
1.
Ethnicity (Select only one box)
indicated above. The interpreter named in Part 6. has
also read the Acknowledgement of Appointment at
Hispanic or Latino
USCIS Application Support Center to me, in the
Not Hispanic or Latino
language in which I am fluent, and I understand this
2.
Race (Select all applicable boxes)
Application Support Center (ASC) Acknowledgement
as read to me by my interpreter.
White
2.
I have requested the services of and consented to
Asian
Black or African American
,
American Indian or Alaska Native
who
is
is not an attorney or accredited
representative, preparing this application for me. This
Native Hawaiian or Other Pacific Islander
person who assisted me in preparing my application
has reviewed the Acknowledgement of Appointment
3.
Height
Feet
Inches
at USCIS Application Support Center with me, and
I understand the ASC Acknowledgement.
4.
Weight
Pounds
Form I-212 12/23/16 N
Page 4 of 8
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