Form I-765 - Application For Employment Authorization
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1OMB No. 1615-0040
I-765, Application For
Department of Homeland Security
Employment Authorization
U.S. Citizenship and Immigration Services
Do not write in this block.
Action Block
Fee Stamp
Remarks
A#
Applicant is filing under §274a.12
Application Approved. Employment Authorized / Extended (Circle One)
until
(Date).
(Date).
Subject to the following conditions:
Application Denied.
Failed to establish eligibility under 8 CFR 274a.12 (a) or (c).
Failed to establish economic necessity as required in 8 CFR 274a.12(c)(14), (18) and 8 CFR 214.2(f)
I am applying for:
Permission to accept employment.
Replacement (of lost employment authorization document).
Renewal of my permission to accept employment (attach previous employment authorization document).
Which USCIS Office?
Date(s)
1. Name (Family Name in CAPS) (First)
(Middle)
Results (Granted or Denied - attach all documentation)
2. Other Names Used (include Maiden Name)
12. Date of Last Entry into the U.S. (mm/dd/yyyy)
3. Address in the United States (Street Number and Name)
(Apt. Number)
13. Place of Last Entry into the U.S.
(Town or City)
(State/Country)
(ZIP Code)
14. Manner of Last Entry (Visitor, Student, etc.)
4. Country of Citizenship/Nationality
15. Current Immigration Status (Visitor, Student, etc.)
5. Place of Birth (Town or City)
(State/Province)
(Country)
16. Go to Part 2 of the Instructions, Eligibility Categories. In the space below,
7. Gender
6. Date of Birth (mm/dd/yyyy)
place the letter and number of the category you selected from the instructions
Male
Female
(For example, (a)(8), (c)(17)(iii), etc.).
8. Marital Status
Married
Single
Eligibility under 8 CFR 274a.12
)
)
(
)
(
(
Widowed
Divorced
9. Social Security Number (include all numbers you have ever used) (if any)
17. If you entered the Eligibility Category, (c)(3)(C), in item 16 above, list your
degree, your employer's name as listed in E-Verfy, and your employer's E-
Verify Company Identification Number or a valid E-Verify Client Company
10. Alien Registration Number (A-Number) or I-94 Number (if any)
Identification Number in the space below.
Degree:
11. Have you ever before applied for employment authorization from USCIS?
Employer's Name as listed in E-Verify:
No
Yes
Employer's E-Verify Company Identification Number or a valid E-Verify
(If "Yes," complete below)
Client Company Identification Number
Certification
Your Certification: I certify, under penalty of perjury under the laws of the United States of America, that the foregoing is true and
correct. Furthermore, I authorize the release of any information that U.S. Citizenship and Immigration Services needs to determine
eligibility for the benefit I am seeking. I have read the Instructions in Part 2 and have identified the appropriate eligibility category in
Block 16.
Signature
Telephone Number
Date
Signature of Person Preparing Form, If Other Than Above:
I declare that this document was prepared by me at the
request of the applicant and is based on all information of which I have any knowledge.
Signature
Address
Date
Print Name
Relocated
Initial Receipt
Resubmitted
Completed
Remarks
Approved
Rec'd
Sent
Denied
Returned
Form I-765 (Rev. 01/19/11)Y
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