Form I-905 - Application For Authorization To Issue Certification For Health Care Workers Page 2
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2Explain how your organization meets the standards described in the instructions sheet. (If more space is required, attach a
separate sheet of paper.)
Describe the procedure you will establish for U.S. Citizenship and Immigration Services to use to verify the validity of your
certificates.
Part 2. Signature (
Read the information on penalties in the instructions before completing this section.)
I certify, under penalty of perjury under the laws of the United States of America, that this application and the evidence submitted
with it are all true and correct. If filing this on behalf of an organization, I certify that I am empowered to do so by that organization. I
authorize the release of any information from my records or from the applicant's organization's records that U.S. Citizenship and
Immigration Services needs to determine eligibility for the benefit I am seeking. If this application is approved, I also agree to provide
U.S. Citizenship and Immigration Services with any information that it requests to determine the organization's eligibility to continue
to issue certificates to health care workers.
Signature and Title
Print Name
Date
NOTE: If you do not completely fill out this form or fail to submit required documents listed in the instructions, this application may
be denied.
Part 3. Signature of Person Preparing Form, If Other Than Above (Sign below)
I declare that I prepared this application at the request of the above person and it is based on all information of which I have
knowledge.
Signature
Print Name
Date
Daytime Telephone Number (Area Code
Fax Number (Area Code and
Firm Name and Address (Street Number and Name;
and Number)
Number)
Suite/Room Number; City/Town; State; Zip Code)
E-Mail Address (if any)
Form I-905 (10/30/11) Y Page 2
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