Form I-905 - Application For Authorization To Issue Certification For Health Care Workers Page 2
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3I certify, under penalty of perjury under the laws of the United
Part 1.
Information About the Applicant Filing This
States of America, that the foregoing is true and correct. Copies
Form (continued)
of documents submitted are exact photocopies of unaltered
original documents, and I understand that I may be required to
Explain your organization's expertise, knowledge, and
submit original documents to U.S. Citizenship and Immigration
experience in the health care occupations for which you are
Services (USCIS) at a later date. Furthermore, I authorize the
seeking authorization.
release of any information from my records that USCIS may
need to determine my eligibility for the benefit that I seek.
I furthermore authorize release of information contained in this
form, in supporting documents, and in my USCIS records, to
other entities and persons where necessary for the
administration of U.S. immigration laws.
Explain how your organization meets the standards
described in the instructions sheet.
3.a.
Applicant's Signature
►
3.b.
Date of Signature
(mm/dd/yyyy)
Applicant's Contact Information
Describe the procedure you will establish for U.S.
4.
Applicant's Daytime Telephone Number
Citizenship and Immigration Services to use to verify the
validity of your certificates.
5.
Applicant's E-mail Address
Part 3. Contact Information, Certification, and
Signature of the Interpreter
Interpreter's Full Name
Part 2. Statement, Certification, Signature, and
Contact Information of the Applicant Filing This
Provide the following information concerning the interpreter:
Form
1.a.
Interpreter's Family Name (Last Name)
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
1.b.
Interpreter's Given Name (First Name)
1.a.
I can read and understand English, and have read and
understand each and every question and instruction
on this form, as well as my answer to each question.
2.
Interpreter's Business or Organization Name (if any)
1.b.
The interpreter named in Part 3. has read to me each
and every question and instruction on this form, as
well as my answer to each question, in
Interpreter's Mailing Address
,
3.a.
Street Number
a language in which I am fluent. I understand each
and Name
and every question and instruction on this form as
translated to me by my interpreter, and have
3.b.
Apt.
Ste.
Flr.
provided true and correct responses in the language
indicated above.
3.c. City or Town
2.
I have requested the services of and consented to
3.d. State
3.e. ZIP Code
,
who is
is not
an attorney or accredited
representative, preparing this form for me.
Page 2 of 3
Form I-905 02/11/14 Y
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