Uscis Form I-765 - Application For Employment Authorization Page 2
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222.
(c)(26) Eligibility Category. If you entered the eligibility
Mother's Name (Provide your mother's birth name.)
category (c)(26) in Item Number 20. above, please provide
13.a. Family Name
the receipt number of your H-1B principal spouse's most
(Last Name)
recent Form I-797 Notice of Approval for Form I-129.
13.b. Given Name
(First Name)
14.
Alien Registration Number (A-Number) or Form I-94
23. (c)(35) and (c)(36) Eligibility Category
Number (if any)
a.
If you entered the eligibility category (c)(35) or (c)(36)
in Item Number 20. above, please provide the receipt
number of the Form I-140 beneficiary's Form I-797
15.
Have you ever before applied for employment
Notice of Approval for Form I-140.
authorization from USCIS?
Yes (Complete the following questions.)
b. Have you EVER been arrested for and/or convicted of
Which USCIS Office?
Dates
any crime?
Yes
No
NOTE: If you answered "Yes" to Item Number 23.b.,
Results (Granted or Denied - attach all documentation)
refer to Item Number 5., Item H. or Item I. in the Who
May File Form I-765 section of these Instructions for
information about providing court dispositions.
No (Proceed to Item Number 16.)
Certification
16.
Date of Your Last Arrival or Entry Into the U.S., On or
About (mm/dd/yyyy)
I certify, under penalty of perjury, that the foregoing is true and
correct. Furthermore, I authorize the release of any information
that U.S. Citizenship and Immigration Services needs to
17.
Place of Your Last Arrival or Entry Into the U.S.
determine eligibility for the benefit I am seeking. I have read
the Who May File Form I-765 section of the Instructions and
have identified the appropriate eligibility category in Item
18.
Status at Last Entry (B-2 Visitor, F-1 Student, No Lawful
Number 20.
Status, etc.)
Applicant's Signature
19.
Current Immigration Status (Visitor, Student, etc.)
Date of Signature (mm/dd/yyyy)
Telephone Number
20. Eligibility Category. Go to the Who May File Form
I-765? section of the Instructions. In the space below, place
the letter and number of the eligibility category you selected
from the instructions. For example, (a)(8), (c)(17)(iii), etc.
Signature of Person Preparing Form, If Other Than
Applicant
(
)
(
)
(
)
I declare that this document was prepared by me at the request
21.
(c)(3)(C) Eligibility Category. If you entered the eligibility
of the applicant and is based on all information of which I have
category (c)(3)(C) in Item Number 20. above, list your
any knowledge.
degree, your employer's name as listed in E-Verify, and
your employer's E-Verify Company Identification Number
Preparer's Signature
or a valid E-Verify Client Company Identification Number
in the space below.
Date of Signature (mm/dd/yyyy)
Degree
Employer's Name as listed in E-Verify
Printed Name
Employer's E-Verify Company Identification Number or a
Valid E-Verify Client Company Identification Number
Address
Form I-765 07/17/17 N
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