Form I-910 - Application For Civil Surgeon Designation Page 4
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72.c.
Street Number
Part 5. Medical Degrees (continued)
and Name
School 2
2.d.
Apt.
Ste.
Flr.
2.a. School Name
2.e. City or Town
2.f.
State
2.g. ZIP Code
2.b.
Dates of Attendance (mm/dd/yyyy)
From
To
2.h.
Employer's Daytime Telephone Number
2.c. Degree
Part 7. Applicant's Statement, Contact
Information, Certification, and Signature
Part 6. Professional Experience
You must establish that you have practiced medicine as a
NOTE: Read the Penalties section of the Form I-910
physician (M.D. or D.O.) for at least four years to be eligible for
Instructions before completing this part. You must file Form
designation.
I-910 while in the United States.
NOTE: In calculating whether you meet the requirement of
Applicant's Statement
four years' practice as a physician, DO NOT count your
post graduate medical training in an internship or residency
NOTE: If applicable, select the box for Item Number 1.
program. You can, however, count the time you practiced
medicine on the basis of a post-residency fellowship.
1.
At my request, the preparer named in Part 8.,
Submit evidence to establish your professional experience,
,
such as evaluations, certificates of completion, business tax
prepared this application for me based only upon
returns and business license (for self-employed physicians),
information I provided or authorized.
or letters of employment verification. If you need extra space
to complete this section, use the space provided in Part 9.
Applicant's Contact Information
Additional Information.
2.
Applicant's Daytime Telephone Number
Employer 1
1.a. Employer's Name
3.
Applicant's Mobile Telephone Number (if any)
1.b.
Dates of Employment (mm/dd/yyyy)
4.
Applicant's Email Address (if any)
From
To
1.c.
Street Number
and Name
Applicant's Certification
1.d.
Apt.
Ste.
Flr.
By signing this application, I accept civil surgeon designation if
1.e. City or Town
my request for designation is granted. Once designated as a
civil surgeon, I agree that I will perform the medical
1.f.
State
1.g. ZIP Code
examinations according to the regulations published by Health
and Human Services (HHS) at 42 CFR 34 and the Technical
1.h.
Employer's Daytime Telephone Number
Instructions for Civil Surgeons by the Centers for Disease
Control and Prevention (CDC), including periodic updates.
By signing this application, I further agree to comply fully with
Employer 2
the regulations at 8 CFR 232. I understand that USCIS reserves
the right to revoke civil surgeon designation in certain
2.a. Employer's Name
circumstances.
Dates of Employment (mm/dd/yyyy)
2.b.
From
To
Form I-910 12/23/16 N
Page 4 of 7
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