Form I-910 - Application For Civil Surgeon Designation
Download a blank fillable Form I-910 - Application For Civil Surgeon Designation in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form I-910 - Application For Civil Surgeon Designation with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7Application for Civil Surgeon Designation
USCIS
Form I-910
Department of Homeland Security
OMB No. 1615-0114
U.S. Citizenship and Immigration Services
Expires 05/31/2018
Barcode
Action Block
Initial Receipt (mm/dd/yyyy)
For
Resubmitted (mm/dd/yyyy)
USCIS
Received
Sent
Use
Only
Remarks
CSID Number:
Select this box if
Attorney State Bar Number
Attorney or Accredited Representative
To be completed by an
Form G-28 is
(if applicable)
USCIS Online Account Number (if any)
attorney or accredited
attached to represent
representative (if any).
the applicant.
►
START HERE - Type or print in black ink.
NOTE: If you answered "Yes" to Item Numbers 2.a. or 3.a.
Part 1. Information About You
above, include a typed or printed explanation of the
circumstances surrounding the revocation or voluntary
1.a. Have you ever been designated as a civil surgeon?
termination in Part 9. Additional Information.
Yes
No
Your Full Name
If you answered "Yes," provide the following information.
4.a. Family Name
1.b.
Period of Designation (mm/dd/yyyy)
(Last Name)
From
To
4.b. Given Name
(First Name)
U.S. Citizenship and Immigration Services (USCIS)
1.c.
office that granted the designation
4.c. Middle Name
Other Names Used
1.d.
Civil Surgeon Identification Number (CSID) (if known)
List all other names you have ever used, including aliases,
maiden name, and nicknames. If you need extra space to
complete this section, use the space provide in Part 9.
2.a. Has USCIS ever revoked your designation?
Additional Information.
Yes
No
5.a. Family Name
If you answered "Yes," provide the following information.
(Last Name)
5.b. Given Name
2.b.
Date of Revocation
(mm/dd/yyyy)
(First Name)
3.a. Have you ever voluntarily terminated your designation?
5.c.
Middle Name
Yes
No
Other Information
If you answered "Yes," provide the following information.
3.b.
Date of Voluntary Termination (mm/dd/yyyy)
6.
Date of Birth (mm/dd/yyyy)
7.
Gender
Male
Female
8.
USCIS Online Account Number (if any)
►
Form I-910 12/23/16 N
Page 1 of 7
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal