Optional Practical Training & Employment Authorizationapplication Procedures Page 2
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3OMB No. 1115-0163; Expires 04/30/05
U.S. Department of Justice
Application for Employment Authorization
Immigration and Naturalization Service
Do Not Write in This Block.
Action Stamp
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).
(Middle)
11. Have you ever before applied for employment authorization from INS?
1. Name (Family Name in CAPS) (First)
Yes
No
(If yes, complete below)
Date(s)
2. Other Names Used (Include Maiden Name)
Which INS Office?
3. Address in the United States (Number and Street)
(Apt. Number)
Results (Granted or Denied - attach all documentation)
(Town or City)
(State/Country)
(ZIP Code)
12. Date of Last Entry into the U.S. (Month/Day/Year)
13. Place of Last Entry into the U.S.
4. Country of Citizenship/Nationality
5. Place of Birth (Town or City)
(State/Province)
(Country)
14. Manner of Last Entry (Visitor, Student, etc.)
7. Sex
15. Current Immigration Status (Visitor, Student, etc.)
6. Date of Birth
Male
Female
16. Go to Part 2 of the Instructions, Eligibility Categories. In the space
Married
Single
8. Marital Status
below, place the letter and number of the category you selected from the
Widowed
Divorced
instructions (For example, (a)(8), (c)(17)(iii), etc.).
9. Social Security Number (Include all Numbers you have ever used) (if any)
Eligibility under 8 CFR 274a.12
10. Alien Registration Number (A-Number) or I-94 Number (if any)
)
(
)
(
)
(
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 which the Immigration and Naturalization Service 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
Date
Telephone Number
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
Completed
Initial Receipt
Resubmitted
Rec'd
Sent
Approved
Denied
Returned
Form I-765 (Rev. 5/09/02)Y
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