Form I-566 - Interagency Record Of Request - A, G Or Nato Dependent Employment Authorization Or Change/adjustment To/from A, G Or Nato Status

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Interagency Record of Request -
A, G, or NATO Dependent Employment Authorization or
USCIS
Change/Adjustment To/From A, G, or NATO Status
Form I-566
Department of Homeland Security
OMB No. 1615-0027
U.S. Citizenship and Immigration Services
Expires 05/31/2018
Attorney State Bar Number
Select this box if
Attorney or Accredited Representative
To be completed by an
(if applicable)
Form G-28 is
USCIS Online Account Number (if any)
attorney or accredited
attached.
representative (if any).
START HERE - Type or print in black ink.
6.
Country of Citizenship or Nationality
Part 1. Information About You (The person
seeking employment authorization or change/
adjustment of status.)
7.
Gender
Male
Female
Full Name
8.
Marital Status
Single
Married
Divorced
1.a. Family Name
(Last Name)
Widowed
Legally Separated
1.b. Given Name
(First Name)
Marriage Annulled
Other
1.c. Middle Name
9.
Alien Registration Number (A-Number) (if any)
A-
Physical Address
10.
U.S. Social Security Number (if any)
2.a.
Street Number
and Name
11.
DOS Personal Identification Number (PID)
2.b.
Apt.
Ste.
Flr.
2.c. City or Town
12.
USCIS Online Account Number (if any)
2.d. State
2.e. ZIP Code
13.
Form I-94 Arrival-Departure Record Number
Mailing Address
3.a.
In Care Of Name
14.
Passport or Travel Document Number
3.b.
Street Number
15.
Country of Issuance for Passport or Travel Document
and Name
3.c.
Apt.
Ste.
Flr.
16.
Expiration Date for Passport or Travel Document
3.d. City or Town
(mm/dd/yyyy)
3.e. State
3.f.
ZIP Code
17.
Date of Last Entry into United States (mm/dd/yyyy)
Other Information
18.
Current Immigration Status
4.
Date of Birth (mm/dd/yyyy)
5.
Country of Birth
19.
Relationship to Principal (if applicable)
Form I-566 12/07/16 N
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