Form I-566 - Interagency Record Of Request Page 2
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4Part 5. Your Personal Information
Your Name (family, given, middle)
Date of Birth (mm/dd/yyyy)
DOS Personal Identification # (PID)
For Official Use Only
Part 6. Certification by Diplomatic Mission, International Organization, NATO/HQ SACT, or
NATO Member State
(Certifying official must have this information and page to complete process.)
I certify that the information provided on the first page of this Form I-566 is true and correct to the best of my knowledge and
according to our official records.
As an applicant for employment authorization, I further certify that his or her eligibility has been verified under the provisions of:
A bilateral agreement with:
A de facto agreement with:
Check each of the following that apply:
Based on principal alien's G-4 status
Without a numerical limit
With a numerical limit and this applicant is within the limit; and
As an applicant for status as a principal alien, I further
and was notified to the DOS on (date):
certify that he or she is being offered the position of:
Signature of Certifying Officer or Official
Printed Name
Official Seal
Name and Address of Diplomatic Mission, International Organization, NATO/HQ SACT, or
NATO Member State
Date (mm/dd/yyyy)
Duty/Title
Phone Number (include area code)
Part 7. DOS, NATO/HQ SACT, and/or USUN Use Only
1. The Department of State, NATO/HQ SACT, and/or USUN:
Recommends the request be granted
Recommends the request be denied
If the recommendation is for denial, provide a reason(s) for such recommendation:
3. Phone Number (include area code)
2. Date (mm/dd/yyyy)
4. Office:
Protocol
USUN
NATO/HQ SACT
Visa
Signature 2
4. Signature 1
Part 8. USCIS Use Only
1. From:
A-Number / File No.
Office Phone Number (with area code)
USCIS Office
Adjudicator's Identification #
2. To:
Visa Office
USUN
(Subject filed under Section 13. Please advise USCIS of your findings.)
Protocol
NATO/HQ SACT
3. Adjustment or Change of Status:
Date of Decision (mm/dd/yyyy)
If change of status granted, give new status:
Granted
Denied
4. Request for Employment Authorization:
Date of Decision (mm/dd/yyyy):
Valid to (mm/dd/yyyy):
Classification:
Denied
Granted
DOS/NATO/HQ SACT/USUN/Visa
5.
Date of Notification (mm/dd/yyyy):
Office Notified:
Yes
No
Copy 1: USCIS
Form I-566 (Rev. 01/18/11) Y Page 2
Copy 2: DOS/NATO/HQ SACT/USUN/VISA OFFICE
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