Form I-360 - Petition For Amerasian, Widow(Er), Or Special Immigrant Page 12
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19Part 9. Complete Only If Filing a Special Immigrant Religious Worker Petition (continued)
Printed Name and Title of Signatory for Prospective Employer
15.
Family Name (Last Name)
Given Name (First Name)
Middle Name
16.
Title of the Signatory
Mailing Address
17.
Employer/Organization Name
Street Number and Name
Apt.
Ste.
Flr. Number
City or Town
State
ZIP Code
Contact Information
18.
Daytime Telephone Number
19.
Fax Number (if any)
20.
Email Address (if any)
Religious Denomination Certification (to be completed only if the prospective employer is affiliated with a
religious denomination)
I certify under penalty of perjury, that the prospective employer,
,
is affiliated with this Religious Denomination,
, and that the attesting
religious organization within the religious denomination is tax-exempt as described in section 501(c)(3) of the Internal Revenue Code
of 1986, or equivalent sections of prior enactments of the Internal Revenue Code. The contents of this certification are true and
correct to the best of my knowledge.
21.
Signature of the Authorized Representative of the Religious Denomination (sign in ink)
Date of Signature (mm/dd/yyyy)
Printed Name and Title of the Signatory of the Religious Denomination
22.
Family Name (Last Name)
Given Name (First Name)
Middle Name
23.
Title of the Signatory
Form I-360 12/23/16 N
Page 12 of 19
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