Form I-212 - Application For Permission To Reapply For Admission Into The United States After Deportation Or Removal Page 5
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8I furthermore authorize release of information contained in this
Part 5. Applicant's Statement, Contact
application, in supporting documents, and in my USCIS records
Information, Acknowledgement of Appointment
to other entities and persons where necessary for the
at USCIS Application Support Center,
administration and enforcement of U.S. immigration laws.
Certification, and Signature (continued)
I certify, under penalty of perjury, that the information in my
application and any document submitted with my application
Applicant's Contact Information
were provided by me and are complete, true, and correct.
3.
Applicant's Daytime Telephone Number
Applicant's Signature
4.
Applicant's Mobile Telephone Number (if any)
6.a.
Applicant's Signature
5.
Applicant's Email Address (if any)
6.b.
Date of Signature (mm/dd/yyyy)
NOTE TO ALL APPLICANTS: If you do not completely fill
out this application or fail to submit required documents listed
Acknowledgement of Appointment at USCIS
in the instructions, USCIS may deny your application.
Application Support Center
I,
,
Part 6. Interpreter's Contact Information,
understand that the purpose of a USCIS ASC appointment is
Certification, and Signature
for me to provide fingerprints, photograph, and/or signature
Provide the following information concerning the interpreter.
and to re-affirm that all of the information in my application is
complete, true, and correct and was provided by me. I
Interpreter's Full Name
understand that I will sign my name to the following
declaration which USCIS will display to me at the time I
1.a.
Interpreter's Family Name (Last Name)
provide my fingerprints, photograph, and/or signature during
my ASC appointment.
By signing here, I declare under penalty of perjury that I
1.b.
Interpreter's Given Name (First Name)
have reviewed and understand my application, petition, or
request as identified by the receipt number displayed on the
screen above, and all supporting documents, applications,
2.
Interpreter's Business or Organization Name (if any)
petitions, or requests filed with my application, petition, or
request that I (or my attorney or accredited representative)
filed with USCIS, and that all of the information in these
Interpreter's Mailing Address
materials is complete, true, and correct.
I also understand that when I sign my name, provide my
3.a.
Street Number
and Name
fingerprints, and am photographed at the USCIS ASC, I will be
re-affirming that I willingly submit this application; I have
3.b.
Apt.
Ste.
Flr.
reviewed the contents of this application; all of the information in
my application and all supporting documents submitted with my
3.c. City or Town
application were provided by me and are complete, true, and
correct; and if I was assisted in completing this application, the
3.d. State
3.e. ZIP Code
person assisting me also reviewed this Acknowledgement of
Appointment at USCIS Application Support Center with me.
3.f.
Province
Applicant's Certification
3.g.
Postal Code
Copies of documents I have submitted are exact photocopies of
3.h. Country
unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date.
Furthermore, I authorize the release of any information from any
and all of my records that USCIS may need to determine my
eligibility for the immigration benefit that I seek.
Form I-212 12/23/16 N
Page 5 of 8
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