Instructions For Application For Civil Surgeon Designation (Form I-910) (Page 4 of 10) in pdf

Item Numbers 1.a. - 1.d. General Information about Previous Civil Surgeon Designation. If you were previously

designated as a civil surgeon, select “Yes” and provide the period of prior designation, the USCIS office that granted the

designation, and the CSID Number issued, if known.

Item Numbers 2.a. - 2.b. Revocation. If USCIS revoked your previous civil surgeon designation, select “Yes” and

provide the date of revocation. Attach the revocation letter you received from USCIS, and also include a typed or written

explanation of the circumstances surrounding the revocation in a separate letter attached to this application or in Part 9.

Additional Information. Please note that USCIS may deny your application for civil surgeon designation if the grounds

upon which your previous designation was revoked still exist.

Item Numbers 3.a. - 3.b. Voluntary Termination. If you voluntarily terminated your previous civil surgeon

designation, select “Yes” and provide the date of voluntary termination. You must also include a typed or written

explanation of the circumstances surrounding the voluntary termination in a separate letter attached to this application or

in Part 9. Additional Information.

Item Numbers 4.a. - 4.c. Your Full Name. Provide your last, first, and middle names in the appropriate fields.

Item Numbers 5.a. - 5.c. Other Names Used. Provide all the names you have used, including your maiden name,

nicknames, and aliases, if applicable.

Item Number 6. Date of Birth. Provide your date of birth in mm/dd/yyyy format.

Item Number 7. Gender. Select the box that indicates whether you are male or female.

Item Number 8. USCIS Online Account Number (if any). If you have previously filed an application, petition, or

request using the USCIS online filing system (previously called USCIS Electronic Immigration System (USCIS ELIS)),

provide the USCIS Online Account Number you were issued by the system. You can find your USCIS Online Account

Number by logging in to your account and going to the profile page. If you previously filed certain applications, petitions,

or requests on a paper form via a USCIS Lockbox facility, you may have received a USCIS Online Account Access Notice

issuing you a USCIS Online Account Number. If you received such a notice, your USCIS Online Account Number can be

found at the top of the notice. If you were issued a USCIS Online Account Number, enter it in the space provided. The

USCIS Online Account Number is not the same as an A-Number.

Part 2. Clinical Office Locations

A. Required Information

Item Numbers 1. - 5. Provide the name, physical address, telephone number, fax number, and email address of the

clinic or practice where you intend to perform immigration medical examinations if granted civil surgeon designation.

Failure to provide this information may result in the denial of your application.

If you seek to perform immigration medical examinations in more than one location, provide the details for each

additional location in Part 9. Additional Information.

NOTE: You must currently have an active practice at the locations where you are requesting to perform immigration

medical examinations. USCIS will not grant civil surgeon designation for locations where you only intend to practice

in the future.

NOTE REGARDING PHYSICAL ADDRESS: The physical address is the address where you are practicing

medicine and where applicants will come to have the medical examination performed. The physical address must

match with the location of your medical clinic or practice.

B. Additional Office Information

Item Numbers 6. - 14. You may submit additional information to USCIS to be included in the public list of civil

surgeons. USCIS displays this information on our website for people who want to find a civil surgeon. USCIS will

update the public list with this information when feasible.

Form I-910 Instructions 12/23/16 N

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Instructions For Application For Civil Surgeon Designation (Form I-910) Page 4