Form I-910 - Application For Civil Surgeon Designation Page 3
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7Part 4. Medical Licenses
Part 3. Information About Your Status in the
United States (continued)
You must be licensed to practice medicine in the state or
territory in which you seek to perform immigration medical
3.
I am currently present in the United States as a
examinations to be eligible for civil surgeon designation.
nonimmigrant (Attach a copy of your Form I-94
Attach a copy of each medical license listed below. If you
Arrival-Departure Record, a copy of your passport or
need extra space to complete this section, use the space
travel document, and any documents related to your
provided in Part 9. Additional Information.
nonimmigrant status, such as a copy of the petition,
petition approval, and change or extension of status
Medical License 1
application. Also attach a copy of your valid,
1.a. State
OR
unexpired Employment Authorization Document as
proof of your authorization to work in the United
U.S. Territory
States, if required.)
1.b. Medical License Number
4.a.
Date of Last Arrival in the U.S. (mm/dd/yyyy)
1.c.
Date Issued (mm/dd/yyyy)
4.b. Form I-94 Arrival-Departure Record Number (if any)
►
1.d.
Date Expires (mm/dd/yyyy)
4.c.
Passport Number
Medical License 2
4.d. Travel Document Number
2.a. State
OR
4.e. Country of Issuance for Passport or Travel Document
U.S. Territory
2.b. Medical License Number
4.f.
Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
2.c.
Date Issued (mm/dd/yyyy)
4.g.
Current Nonimmigrant Status
2.d.
Date Expires (mm/dd/yyyy)
5.
I have been granted another status under U.S.
Part 5. Medical Degrees
immigration law that allows me to work and to
practice medicine in the United States:
You must possess a medical degree as a Doctor of Medicine
(M.D.) or Doctor of Osteopathy (D.O.) to be eligible for civil
surgeon designation. Attach a copy of each medical degree
listed below. If you need extra space to complete this section,
use the space provided in Part 9. Additional Information.
School 1
1.a. School Name
1.b.
Dates of Attendance (mm/dd/yyyy)
From
To
1.c. Degree
Form I-910 12/23/16 N
Page 3 of 7
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