Form I-777 - Application For Replacement Of Northern Mariana Card
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2OMB No. 1615-0042; Expires 11/30/2011
Form I-777, Application for Replacement
Department of Homeland Security
of Northern Mariana Card
U.S. Citizenship and Immigration Services
Part 1.
Information About You
FOR USCIS USE ONLY
(Person applying for a Northern Mariana Card)
Returned
Receipt
Family Name (Last Name)
Given Name (First Name)
Middle Name
Date
Date
Home Address - Street Number and Name
Apt. #
Resubmitted
Date
City
State or Province
Date
Reloc Sent
Zip/Postal Code
Country
Date
Date
Mailing Address - Street Number and Name
Apt./Suite #
Reloc Rec'd
C/O (In care of):
Date
Date
City
State or Province
Applicant
Interviewed
on
Zip/Postal Code
Country
A-Number
Daytime Phone # (Area/Country Code)
Gender
Remarks
Male
Female
Date of Birth (mm/dd/yyyy)
Place of Birth (City/Town and Country)
A-Number (If any)
U.S. Social Security # (If any)
Father's First Name
Mother's First Name
Action
Part 2.
Requested Action
Check the classification that best describes your eligibility. (Check one box)
A.
My Northern Mariana Card was lost or destroyed.
B.
My Northern Mariana Card was stolen. (You must attach a copy of the police
report.)
To Be Completed by
Attorney or Representative, if any.
C.
My Northern Mariana Card was damaged. (You must attach the damaged
Fill in box if G-28 is attached
card.)
to represent the applicant.
ATTY State License #
Form I-777 (Rev. 11/19/10) Y
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