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

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OMB No. 1615-0018; Exp. 09/30/2012
Form I-212, Application for Permission to Reapply for Admission
Department of Homeland Security
Into the United States After Deportation or Removal
U.S. Citizenship and Immigration Services
For Government Use Only
Fee Stamp
RET'D-TRANS.-OUT
RECEIVED
TRANS. IN
COMPLETED
Date
This space for use by DHS officer
Date of
File A -
Action
Decision
DD
or
OIC
Office
Applicants Start Here (To be filed in duplicate)
PART I. INFORMATION ABOUT YOU
First Name
Middle Name
Last Name
Alien registration number (A#) if known, or Alien File(s) or receipt number(s) and any immigration file(s)
or case number(s) listed on correspondence from U.S. immigration authorities that relate to you
Name used when last deported or removed
Country of Citizenship
Other names used or known by
from the United States
or Nationality
Date of Birth
Country
Province
Place of Birth (City or Town)
State
PART II. REASON FOR FILING THIS FORM
I am inadmissible to the United States for the following reason(s) and no others:
I have been removed as an arriving alien in expedited removal proceedings under INA section 235(b)(1), or I was removed
at the end of proceedings under INA section 240 as an arriving alien (INA section 212(a)(9)(A)(i)).
I have only been removed once, and my last removal was less than 5 years ago.
I have been removed at least twice or more, and my last removal was less than 20 years ago.
I have been convicted of an aggravated felony (in the United States or elsewhere, before or after my removal from the
United States).
I have been removed as a deportable alien under INA section 240 or any other provision of the law, or I departed the
United States while an order or removal was outstanding (INA section 212(a)(9)(A)(ii)).
I have only been removed once and less than 10 years ago.
I have been removed at least twice or more, and my last removal was less than 20 years ago.
I have been convicted of an aggravated felony (in the United States or elsewhere, before or after my removal from the
United States).
Form I-212 (09/11/11) Y

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