Form I-910 - Application For Civil Surgeon Designation Page 2
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77.
Website Address (URL)
Part 2. Clinical Office Locations
Provide the following information about the locations where
you seek to perform immigration medical examinations. If you
8.
Fees for Medical Examination
seek to perform immigration medical exams in more than one
location, provide the details for each additional location in the
space provided in Part 9. Additional Information.
9.
Acceptable Means of Payment
A. Required Information
You must provide the following information. Failure to provide
10.
Accepted Medical Insurance Plans
this information may result in the denial of your application.
Refer to Part 2., Section B for more information about what
will be made publicly available.
11.
Languages Spoken
1.
Name of Clinic/Practice
Physical Address of the Clinic/Practice
2.a.
Street Number
12.
Office Hours
and Name
2.b.
Apt.
Ste.
Flr.
13.
Handicap Accessibility
2.c.
City or Town
2.d.
State
2.e. ZIP Code
14.
Other
3.
Telephone Number
4.
Fax Number
5.
Email Address (For use by USCIS)
Part 3. Information About Your Status in the
NOTE: USCIS will use the contact information listed above
United States
for all civil surgeon-related communication.
You must be authorized to work in the United States to be
UPDATE USCIS OF ANY CHANGES: Civil surgeons are
eligible for civil surgeon designation. Select the box that
responsible for notifying USCIS in writing of any updates to the
accurately states how you are authorized to work in the United
contact information provided in this application within 15 days
States.
of the change. Visit the USCIS Website at
1.
for information on how to submit a
I am a U.S. citizen or national (Attach proof that you
change.
are a U.S. citizen or national, such as a copy of a U.S.
passport, birth certificate, or Certificate of
Naturalization.)
B. Additional Office Information
2.
I am a Lawful Permanent Resident. (Attach a copy
Your application will not be affected if you choose not to
of your valid Form I-551, Permanent Resident Card.
provide the following information. USCIS displays this
If you are currently seeking to renew or replace your
information on our website for people who want to find a civil
Form I-551, attach evidence showing that you are
surgeon.
doing so.)
6.
Email Address (For use by the public)
Form I-910 12/23/16 N
Page 2 of 7
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