Form I-765v - Application For Employment Authorization For Abused Nonimmigrant Spouse Page 2
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619.b.
Date Current Status Expired or Will Expire, as shown on
Part 1. Information About You (continued)
Form I-94 (mm/dd/yyyy)
U.S. Physical Address
19.c.
Passport Number
9.a. Street Number
and Name
19.d.
Travel Document Number
9.b.
Apt.
Ste.
Flr.
19.e.
Country of Issuance for Passport or Travel Document
9.c. City or Town
19.f.
Expiration Date for Passport or Travel Document
9.d. State
9.e. ZIP Code
(mm/dd/yyyy)
Other Information
20.
Current Immigration Status (for example, A-2, E-3, G-1,
H-4, No Lawful Status)
10.
Sex
Male
Female
11.
Date of Birth (mm/dd/yyyy)
Eligibility Category. Refer to the Who May File Form
21.
I-765V section of the Form I-765V Instructions to
12.a. City or Town of Birth
determine the appropriate eligibility category for this
application. In the space below, enter the letter and
number for your eligibility category. (For example,
12.b.
State or Province of Birth
(c)(27), (c)(28), (c)(29), (c)(30)).
12.c.
Country of Birth
Part 2. Information About Your Spouse
13.
Country of Citizenship or Nationality
Provide the following information, if known.
1.a. Family Name
(Last Name)
14.
Have you EVER applied for employment authorization
1.b. Given Name
from USCIS?
Yes
No
(First Name)
If you answered "Yes" to Item Number 14., provide the
1.c. Middle Name
information requested in Item Numbers 15.a. - 15.b. for
your most recent application.
2.
Date of Birth (mm/dd/yyyy)
15.a.
Which USCIS Office?
Country of Birth
3.
15.b.
What was the result?
Approved
Denied
U.S. Physical Address
NOTE: Attach all documentation from your previous
4.a. Street Number
employment authorization.
and Name
16.
Place of Last Entry into the United States
4.b.
Apt.
Ste.
Flr.
4.c. City or Town
17.
Date of Last Entry into United States, on or about
(mm/dd/yyyy)
4.d. State
4.e. ZIP Code
18.
Immigration Status of Last Entry (for example, A-2, E-3,
G-1, H-4)
Other Information
5.
A-Number (if any)
19.a.
Form I-94 Arrival-Departure Record Number (if any)
A-
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Form I-765V 01/19/17 N
Page 2 of 6
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