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Item Number 8. Gender. Indicate whether you are male or female.

Item Number 9. Date of Birth. Provide your date of birth in mm/dd/yyyy format.

Item Numbers 10. - 12. Place of Birth. Provide the name of the city or town, state or province, and country where you

were born.

Item Number 13. Country of Citizenship or Nationality. Provide the country where you are currently a citizen or

national. If you do not have citizenship in any country, indicate “stateless.”

Item Numbers 14.a. - 14.b. Consent to Reapply Filed with Immigrant or Nonimmigrant Visa Applications. If

you seek an immigrant visa or nonimmigrant visa and are or will file your application for consent to reapply with

your immigrant or nonimmigrant visa application, provide the DOS Consular Case Number for your immigrant or

nonimmigrant visa application (if available) and indicate the location of the U.S. Embassy or U.S. Consulate where you

are seeking or will seek your visa.

Item Numbers 15.a. - 15.c. Consent to Reapply Filed with Adjustment of Status Applications. If you are seeking

consent to reapply in connection with your application to adjust your status to that of a lawful permanent resident or if you

have previously filed an application for adjustment of status, list the USCIS receipt number for your adjustment of status

application and indicate the date and the USCIS office where you filed your application.

Item Numbers 16. - 17.c. Consent to Reapply Filed with Form I-601, Waiver of Grounds of Inadmissibility.

Indicate whether you are submitting your application for consent to reapply with your Form I-601, Waiver of Grounds

of Inadmissibility. If you mark “No,” but have previously filed a Form I-601, provide the USCIS receipt number for that

application and indicate the date and USCIS office where you filed your Form I-601.

Part 2. Reasons You Are Filing Form I-212

Item Numbers 1.a. - 2.b. Removal as an Arriving Alien. Complete this section if you were removed from the United

States as an arriving alien in expedited removal proceedings under INA section 235(b)(1) or at the end of proceedings

under INA section 240. Also indicate either the number of times you have been removed from the United States or if you

were convicted of an aggravated felony at any time before or after removal from the United States. Provide the dates you

were removed from the United States and the location from where you were removed (city or town and state). If you were

convicted, you must submit court documents, police records, or criminal records showing the disposition of your offense.

You also should submit the originals or certified copies that are properly authenticated.

Item Numbers 3.a. - 4.b. Removal as a Deportable Alien. Complete this section if you were removed from the United

States as a deportable alien under INA section 240 or any other provision or law or if you departed while an order of

removal was outstanding. Also indicate either the number of times you have been removed from the United States or

if you were convicted of an aggravated felony at any time before or after removal from the United States. If you were

convicted, you must submit court documents, police records, or criminal records showing the disposition of your offense.

You also should submit the originals or certified copies that are properly authenticated. Also, provide the dates you were

removed from the United States and the location from where you were removed (city or town and state).

Item Numbers 5.a. - 6.d. Entry After Unlawful Presence in the Aggregate of 1 Year. Complete this section if you

entered or attempted to enter the United States without being admitted or paroled after having been unlawfully present in

the United States on or after April 1, 1997, for a period of more than one year, in the aggregate. (See INS section

212(a)(9)(C)(i)(I)). List all periods when you were unlawfully present in the United States, beginning with the most recent

period. Provide the dates and locations (city or town and state) for your departures and entries or attempted reentries.

Attach evidence to establish that you have remained outside of the United States for 10 years since your last departure.

Form I-212 Instructions 12/23/16 N

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Instructions For Form I-212 - Application For Permission To Reapply For Admission Into The United States After Deportation Or Removal Page 10