Application For Permission printable pdf download

OMB No. 1615-0018; Exp. 06/30/2010

Department of Homeland Security

I-212, Application for Permission to Reapply for Admission

U.S. Citizenship and Immigration Services

Into the United States After Deportation or Removal

Fee Stamp

(To be filed in duplicate)

Date (mm/dd/yyyy)

I request permission to reapply for admission into the United States.

1. Name

( Last)

(First)

(Middle)

2. File numbers on correspondence from U.S. Citizenship and Immigration

Services (USCIS) or former Immigration and Naturalization Service

(INS) (if known)

3. Name used when last deported or removed from the U.S.

4. Date of Birth (mm/dd/yyyy)

5. Other names used or known by

6a. Place of Birth (city or town; state or province; and country)

7. Circumstances under which deported or removed from the United

6b. Country of Citizenship/Nationality

States

(Check applicable blocks)

Excluded and deported or removed. (less than one year ago)

8. Length of residence in the United States (years)

Arrested and deported or removed. (less than five years ago)

Removed after having fallen into distress. (less than five years ago) 9. Place of residence at time of deportation or removal from United States

Removed as alien enemy. (less than five years ago)

(city and state)

Removed at U.S. Government expense in lieu of deportation.

(less than five years ago)

10. Place deportation hearing held or application for removal made (city)

11. Country to which deported or removed

12. Detention facility or jail where detained (city and state) (If not

detained, write "None")

13. Date of deportation or removal from United States (mm/dd/yyyy)

14. Port of departure from United States

15. Status desired if permitted to re-enter United States

16. Reasons for desiring to re-enter the United States

Permanent Resident

Visitor

Student

Other (specify)

17. Location of American Embassy/Consulate where application for visa

18. Name and relationship of U.S. citizen or lawful permanent resident

will be made (city and country)

alien spouse, parent or children, if any

19. Signature of Applicant

20. Street and number; city or town; state or province; and country of

present residence

Signature of person preparing form, if other than applicant.

21. 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)

This space for use by DHS officer

File A -

Date of

Action

Decision

OIC

Office

Complete and Submit Both Forms.

RECEIVED

TRANS. IN

RET'D-TRANS.-OUT

COMPLETED

Form I-212 (Rev. 07/30/07)Y

Document hosted at

Application For Permission

Related Articles

Related forms

Related Categories