Instructions For Application For Civil Surgeon Designation (Form I-910) (Page 5 of 10) in pdf

Part 3. Information About Your Status in the United States

In this section, provide information about the immigration status you were granted in the United States that allows you to

work and practice medicine in the United States. Attach evidence establishing your legal status in the United States.

Item Numbers 1. - 4.g. Proof of Your Status in the United States. A physician meeting the professional qualifications

for civil surgeon designation can only be designated as a civil surgeon if authorized to work in the United States. Specify

whether you are a U.S. citizen or national, a lawful permanent resident, a nonimmigrant authorized to work as a physician

in the United States, or another status that would allow you to practice medicine in the United States.

1. If you select Item Number 1., submit proof that you are a U.S. citizen or national, such as a copy of a U.S. passport,

birth certificate, or Certificate of Naturalization.

2. If you select Item Number 2., submit a copy of your valid Form I-551, Permanent Resident Card. If you are

currently seeking to renew or replace your Form I-551, submit evidence showing that you are doing so.

3. If you select Item Number 3., you must also provide the information requested in Item Numbers 4.a. - 4.g.

Item Number 4.a. Date of Last Arrival in the U.S. (mm/dd/yyyy). The date of your last arrival to the United

States.

Item Number 4.b. Form I-94 Arrival-Departure Record Number (if any). If U.S. Customs and Border Protection

(CBP) or USCIS issued you a Form I-94, Arrival-Departure Record, provide your Form I-94 number and date that

your authorized period of stay expires or expired (as shown on Form I-94). The Form I-94 number also is known as

the Departure Number on some versions of Form I-94.

NOTE: If you were admitted to the United States by CBP at an airport or seaport after April 30, 2013, you may have

been issued an electronic Form I-94 by CBP, instead of a paper Form I-94. You may visit the CBP website at

to obtain a paper version of an electronic Form I-94. CBP does not charge a fee for this service.

Some travelers admitted to the United States at a land border, airport, or seaport, after April 30, 2013 with a passport

or travel document, who were issued a paper Form I-94 by CBP, may also be able to obtain a replacement Form

I-94 from the CBP website without charge. If your Form I-94 cannot be obtained from the CBP website, it may be

obtained by filing Form I-102, Application for Replacement/Initial Nonimmigrant Arrival-Departure Record, with

USCIS. USCIS does charge a fee for this service.

Item Numbers 4.c. - 4.g. Passport and Travel Document Numbers. If you used a passport or travel document to

travel to the United Sates, enter either the passport or travel document information in the appropriate space on the

application, even if the passport or travel document is currently expired.

4. Item Number 5., enter information in the space provided about any other status you were granted under U.S.

immigration law in the United States that allows you to work and to practice medicine in the United States.

Part 4. Medical Licenses

Item Numbers 1.a. - 2.d. You must be licensed to practice medicine in the U.S. state(s) or U.S. territories in which

you perform immigration medical examinations. For each U.S. state or U.S. territory in which you seek to perform

immigration medical examinations, provide the name of the U.S. state or U.S. territory that issued your medical license,

the medical license number, the date the medical license was issued, and the date it expires. Attach a copy of each of your

medical licenses to your application.

Part 5. Medical Degrees

Item Number 1.a. - 2.c. Only Doctors of Medicine (M.D.) and Doctors of Osteopathy (D.O.) may be designated as

civil surgeons. Provide the names of the schools you attended, your dates of attendance, and the type of medical degrees

earned. Attach a copy of each of your medical degrees to your application.

Part 6. Professional Experience

Item Numbers 1.a. - 2.h. To be designated as a civil surgeon, you must establish that you have practiced medicine as

a physician (M.D. or D.O.) for at least four years. Provide your employers’ names, the dates of employment, and your

employers’ contact information to cover a period of at least four years. .

Form I-910 Instructions 12/23/16 N

Page 5 of 10

Instructions For Application For Civil Surgeon Designation (Form I-910) Page 5

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