Form I-693 - Report Of Medical Examination And Vaccination Record Page 2
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13Family Name (Last Name)
Given Name (First Name)
Middle Name
A-Number (if any)
A-
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Part 2. Applicant's Statement, Contact Information, Certification, and Signature (continued)
Applicant's Certification
I authorize the release of any information from any of my records that USCIS may need to determine my eligibility for the
immigration benefit I seek.
I further authorize release of information contained in this form, in supporting documents, and in my USCIS records to other entities
and persons where necessary for the administration and enforcement of U.S. immigration laws.
I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or
signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that:
1) I reviewed and provided or authorized all of the information in my form;
2) I understood all of the information contained in, and submitted with, my form; and
3) All of this information was complete, true, and correct at the time of filing.
I certify, under penalty of perjury that I am the person who is identified in Part 1. of this Form I-693, and that the information in
Part 1. of this form is complete, true, and correct. I understand the purpose of this medical examination, and I authorize the
required tests and procedures to be completed. If it is determined that I willfully misrepresented a material fact or provided false or
altered information or documents with regard to my medical examination, I understand that any immigration benefit I derived from
this medical examination may be revoked, that I may be removed from the United States, and that I may be subject to civil or
criminal penalties.
Applicant's Signature
NOTE: Do not sign or date Form I-693 until instructed to do so by the civil surgeon.
5.
Applicant's Signature
Date of Signature
(mm/dd/yyyy)
NOTE TO ALL APPLICANTS AND CIVIL SURGEONS: If you or the civil surgeon do not completely fill out this form
according to the instructions USCIS may deny your immigration benefit.
Part 3. Interpreter's Contact Information, Certification, and Signature
Provide the following information about the interpreter.
Interpreter's Full Name
1.
Interpreter's Family Name (Last Name)
Interpreter's Given Name (First Name)
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Interpreter's Business or Organization Name (if any)
Form I-693 10/19/17 N
Page 2 of 13
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