Form I-765v - Application For Employment Authorization For Abused Nonimmigrant Spouse
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6Application for Employment Authorization for
Abused Nonimmigrant Spouse
USCIS
Form I-765V
Department of Homeland Security
OMB No. 1615-0137
U.S. Citizenship and Immigration Services
Expires 01/31/2019
Action Block
Fee Stamp
For USCIS Use Only
A-
EAD Code Assigned: (c)
Initial Receipt
Completed
Relocated
Remarks
Approved
Received
Resubmitted
Denied
Sent
Returned
Authorization/Extension Valid From
Application Denied
Application
Approved
Authorization/Extension Valid To
Attorney State Bar Number
Attorney or Accredited Representative
Select this box if
To be completed by an
(if applicable)
USCIS Online Account Number (if any)
Form G-28 is
Attorney or Accredited
attached.
Representative (if any).
START HERE - Type or print in black ink.
►
Part 1. Information About You
Other Names Used (if any)
Provide all other names you have ever used, including aliases,
1.
I am applying for:
maiden name, and nicknames. If you need extra space to
Initial permission to accept employment.
complete this section, use the space provided in Part 7.
Replacement. (Lost, stolen, mutilated card, or my
Additional Information.
card contains incorrect information not attributed to
Family Name
6.a.
U.S. Citizenship and Immigration Services (USCIS)
(Last Name)
error.)
Given Name
6.b.
(First Name)
Renewal of my permission to accept employment.
(Attach a copy of your previous employment
6.c.
Middle Name
authorization document.)
2.
Alien Registration Number (A-Number) (if any)
Safe Mailing Address
A-
►
NOTE: If you do not want USCIS to send notices about this
application to your home, you may provide an alternate safe
3.
USCIS Online Account Number (if any)
mailing address.
►
7.a.
In Care Of Name (if any)
4.
U.S. Social Security Number (if any)
►
7.b.
Street Number
and Name
Your Full Name
7.c.
Apt.
Ste.
Flr.
NOTE: USCIS will issue your card in this name.
7.d. City or Town
5.a.
Family Name
(Last Name)
7.e. State
7.f.
ZIP Code
5.b.
Given Name
(First Name)
8.
Is your current U.S. physical address the same as your
5.c.
Middle Name
safe mailing address?
Yes
No
If you answered "No" to Item Number 8., provide your
U.S. physical address in Item Numbers 9.a. - 9.e.
Form I-765V 01/19/17 N
Page 1 of 6
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