Instructions For Application For Civil Surgeon Designation (Form I-910) (Page 6 of 10) in pdf

NOTE: In calculating whether you meet the requirement of four years’ practice as a physician, DO NOT count your

post graduate medical training in an internship or residency program. You can, however, count the time you practiced

medicine on the basis of a post-residency fellowship. Submit evidence establishing your professional experience, such as

evaluations, certificates of completion, business tax returns and business licenses (for self-employed physicians), or letters

of employment verification.

Part 7. Applicant’s Statement, Contact Information, Certification, and Signature

Item Numbers 1.a. - 5.b. If someone assisted you in completing the application, select the box indicating that you used a

preparer. Further, you must sign and date your application and provide your daytime telephone number, mobile telephone

number (if any), and email address (if any). Every application MUST contain the signature of the applicant (or parent or

legal guardian, if applicable). A stamped or typewritten name in place of a signature is not acceptable..

Part 8. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than

the Applicant

Item Numbers 1.a. - 9.b. This section must contain the signature of the person who completed your application, if

other than you, the applicant. If the person who completed this application is associated with a business or organization,

that person should complete the business or organization name and address information. Anyone who helped you

complete this application MUST sign and date the application. A stamped or typewritten name in place of a signature

is not acceptable. If the person who helped you prepare your application is an attorney or accredited representative, he

or she may be obliged to also submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited

Representative, along with your application. Select Item Number 7. if the preparer may act as a secondary point of

contact for you, if USCIS is unable to contact you using the information provided in Part 2. Clinical Office Locations.

Part 9. Additional Information

Item Numbers 1.a. - 7.d. If you need extra space to provide any additional information within this application, use the

space provided in Part 9. Additional Information. If you need more space than what is provided in Part 9., you may

make copies of Part 9. to complete and file with your application, or attach a separate sheet of paper. Include your name

at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and

sign and date each sheet.

You may also submit a statement with additional information in a separate letter, but you must annotate in Part 9.

Additional Information that you are attaching a separate letter. The letter must be submitted at the same time as this

Form I-910 application, and make reference to the Page Number, Part Number, and Item Number of Form I-910 to

which the additional information relates. Also include your full name and CSID Number, if you have one, on each page

of the letter.

We recommend that you print or save a copy of your completed application to review in the future and for

your records.

What Is the Filing Fee?

The filing fee for Form I-910 is $785.

There is no fee for an application from a medical officer in the U.S. Armed Forces or civilian physician employed by

the U.S. Government who examines members and veterans of the Armed Forced and their dependents at a military,

Department of Veterans Affairs, or U.S. Government facility in the United States.

NOTE: The filing fee is not refundable, regardless of any action USCIS takes on this application. DO NOT MAIL

CASH. You must submit all fees in the exact amount.

Form I-910 Instructions 12/23/16 N

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Instructions For Application For Civil Surgeon Designation (Form I-910) Page 6