Form I-212 - Application For Permission To Reapply For Admission Into The United States After Deportation Or Removal Page 6

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Part 6. Interpreter's Contact Information,
Part 7. Contact Information, Statement,
Certification, and Signature (continued)
Certification, and Signature of the Person
Preparing this Application, If Other Than the
Interpreter's Contact Information
Applicant
4.
Interpreter's Daytime Telephone Number
Provide the following information concerning the preparer.
Preparer's Full Name
5.
Interpreter's Email Address (if any)
1.a. Preparer's Family Name (Last Name)
Interpreter's Certification
1.b.
Preparer's Given Name (First Name)
I certify that:
I am fluent in English and
,
2.
Preparer's Business or Organization Name (if any)
which is the same language provided in Part 5., Item Number
1.b.;
I have read to this applicant every question and instruction on
Preparer's Mailing Address
this application, as well as the answer to every question, in the
language provided in Part 5., Item Number 1.b.; and
3.a.
Street Number
and Name
I have read the Acknowledgement of Appointment at USCIS
Application Support Center to the applicant in the same
3.b.
Apt.
Ste.
Flr.
language provided in Part 5., Item Number 1.b.
3.c. City or Town
The applicant has informed me that he or she understands every
instruction and question on the application, as well as the answer
3.d. State
3.e. ZIP Code
to every question, and the applicant verified the accuracy of
every answer; and
3.f.
Province
The applicant has also informed me that he or she understands the
ASC Acknowledgement and that by appearing for a USCIS ASC
3.g.
Postal Code
biometric services appointment and providing his or her
fingerprints, photograph, and/or signature, he or she is
3.h. Country
re-affirming that the contents of this application and all
supporting documentation are complete, true, and correct.
Preparer's Contact Information
Interpreter's Signature
4.
Preparer's Daytime Telephone Number
Interpreter's Signature
6.a.
5.
Preparer's Fax Number
6.b.
Date of Signature (mm/dd/yyyy)
6.
Preparer's Email Address (if any)
Form I-212 12/23/16 N
Page 6 of 8

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