Form I-765 - Application For Employment Authorization
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1
2USCIS
Application For Employment Authorization
Form I-765
Department of Homeland Security
OMB No. 1615-0040
U.S. Citizenship and Immigration Services
Expires 02/28/2018
Action Block
Initial Receipt
Resubmitted
Fee Stamp
For
USCIS
Relocated
Use
Received
Sent
Only
Completed
Application Denied - Failed to establish:
Approved
Denied
Application Approved
Eligibility under
Economic necessity under
Authorization/Extension Valid From
8 CFR 274a.12
8 CFR 274a.12(c)(14), (18)
A#
(a) or (c)
and 8 CFR 214.2(f)
Authorization/Extension Valid To
Subject to the following conditions:
Applicant is filing under section 274a.12
►
START HERE - Type or print in black ink.
I am applying for:
Permission to accept employment.
Replacement (of lost employment authorization document).
7. Gender
Male
Female
Renewal of my permission to accept employment (attach a
8.
Marital Status
copy of your previous employment authorization
Single
Married
Divorced
Widowed
document).
9.a.
Has the Social Security Administration (SSA) ever
1.
Full Name
officially issued a Social Security card to you?
Family Name
First Name
Middle Name
Yes
No
Gupta
ABC
NOTE: If you answered “Yes” to Item Number 9.a.,
2.
Other Names Used (include Maiden Name)
provide the information requested in Item Number 9.b.
Family Name
First Name
Middle Name
9.b.
Provide your Social Security number (SSN) (if known)
►
Sharma
ABC
1 2 3 4 5 6 7 8 9
Do you want the SSA to issue you a Social Security card?
10.
(You must also answer “Yes” to Item Number 11.,
Consent for Disclosure, to receive a card.)
3.
U.S. Mailing Address
Yes
No
Street Number and Name
Apt. Number
NOTE: If you answered “No” to Item Number 10., skip
12 Glen Ave
12
to Item Number 14. If you answered “Yes” to Item
Number 10., you must also answer “Yes” to Item
Town or City
State
ZIP Code
Number 11.
Boston
MA
01234
Consent for Disclosure: I authorize disclosure of
11.
4.
Country of Citizenship or Nationality
information from this application to the SSA as required
for the purpose of assigning me an SSN and issuing me a
INDIA
Social Security card.
Yes
No
5.
Place of Birth
NOTE: If you answered “Yes” to Item Numbers 10. - 11.,
Town or City
State/Province
Country
provide the information requested in Item Numbers 12.a. - 13.b.
DELHI
DELHI
INDIA
Father's Name
6.
Date of Birth (mm/dd/yyyy)
01/30/1980
12.a. Family Name
(Last Name)
12.b. Given Name
(First Name)
Form I-765 07/17/17 N
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