Instructions For Application For Civil Surgeon Designation (Form I-910) (Page 9 of 10) in pdf

Penalties

If you knowingly and willfully falsify or conceal a material fact or submit a false document with your Form I-910, we will

deny your Form I-910 and may deny any other immigration benefit. In addition, you will face severe penalties provided

by law and may be subject to criminal prosecution.

USCIS Compliance Review and Monitoring

By signing this application, you have stated under penalty of perjury (28 U.S.C. Section 1746) that all information and

documentation submitted with this application is complete, true, and correct. You also authorize the release of any

information from your records that USCIS may need to determine eligibility for the designation you are seeking and

consent to USCIS verifying such information.

DHS has the authority to verify any information you submit to establish eligibility for the immigration benefit you are

seeking at any time. USCIS’ legal authority to verify this information is in 8 U.S.C. Sections 1103 and 1222(b) and

8 CFR Part 232.2(b). To ensure compliance with applicable laws and authorities, USCIS may verify information before

or after your case is decided.

Agency verification methods may include, but are not limited to: review of public records and information; contact via

written correspondence, the Internet, facsimile, other electronic transmission, or telephone; unannounced physical site

inspections of medical clinics or practices; and interviews. USCIS will use information obtained through verification to

assess your compliance with the laws and to determine your eligibility for a benefit.

Subject to the restrictions under 8 CFR Part 103.2(b)(16), USCIS will provide you with an opportunity to address any

adverse or derogatory information that may result from a USCIS compliance review, verification, or site visit after a

formal decision is made on your case or after the agency has initiated an adverse action which may result in revocation or

termination of an approval.

USCIS Privacy Act Statement

AUTHORITIES: USCIS collects the information requested from a physician seeking to be designated by USCIS as a

Civil Surgeon pursuant to Section 232 of the Immigration and Nationality Act, as amended and 8 CFR 232.2.

PURPOSE: The primary purpose for requesting the requested information is to determine whether you are eligible

to be designated as a USCIS Civil Surgeon. USCIS will use the information you provide to determine your eligibility

for designation as a Civil Surgeon. If USCIS does designate you as Civil Surgeon, USCIS will provide your contact

information to USCIS applicants who are required to have an immigration-related medical examination completed by a

USCIS-designated Civil Surgeon.

DISCLOSURE: Providing this information is voluntary. However, failure to provide the requested information, and any

requested evidence, may delay a final decision in your case or result in denial of your request to be designated as a Civil

Surgeon.

ROUTINE USES: USCIS may share the information you provide to USCIS with other federal, state, local, and foreign

government agencies and authorized individuals or organizations in accordance with approved routine uses, as described

in the associated published system of records notices [DHS-USCIS-001 - Alien File, Index, and National File Tracking

System of Records and DHS-USCIS-007 - Benefits Information System] which can be found at

USCIS may also make the information available, as appropriate for law enforcement purposes or in the interest of national

security.

Form I-910 Instructions 12/23/16 N

Page 9 of 10

Instructions For Application For Civil Surgeon Designation (Form I-910) Page 9