Form I-212 - Application For Permission To Reapply For Admission Into The United States After Deportation Or Removal Page 2

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I entered or attempted to enter the United States without being admitted or paroled after having been removed (INA
section 212(a)(9)(C)(i)(I)).
Specify date of last departure from the United States after having become inadmissible: (Attach evidence that demonstrates the
date of your last departure from the United States and that you have remained outside the United States for 10 years.)
I entered or attempted to enter the United States without being admitted or paroled after having been unlawfully
present in the United States for a period of more than 1 year, in the aggregate (INA section 212(a)(9)(C)(i)(I)).
Specify date of last departure from the United States after having become inadmissible: (Attach evidence that demonstrates the
date of your last departure from the United States and that you have remained outside the United States for 10 years.)
PART III. INFORMATION ABOUT YOUR REMOVAL/DEPORTATION AND DEPARTURE
If you have not been in removal proceedings, date of last
Length of residence in the
Date of deportation or removal
departure from the United States (Attach evidence)
from the United States
United States (years)
Place deportation or removal hearing held or
Place of residence at time of deportation or
Country to which deported or
removal from United States (city and state)
application for removal made (city and state)
removed
Detention facility or jail where detained (city and
Port/location of departure from the United States
state) (If not detained, write "None.")
PART IV. REASON(S) FOR YOUR REQUEST FOR PERMISSION TO REAPPLY
Status desired if permitted to reenter the United States:
Other (specify)
Visitor
Student
Permanent Resident
Reason(s) for desiring to reenter the United States:
Form I-212 (09/11/11) Y Page 2

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