Form I-212 - Application For Permission To Reapply For Admission Into The United States After Deportation Or Removal - 2005 Page 3
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4OMB No. 1615-0018; Exp. 11-30-05
I-212, Application for Permission to Reapply for Admission
Department of Homeland Security
Into the United States After Deportation or Removal
U.S. Citizenship and Immigration Services
Fee Stamp
(To be filed in duplicate)
Date (mm/dd/yyyy)
I request permission to reapply for admission into the United States.
1. Name
2. File numbers on correspondence from U.S. Citizenship and Immigration
( Last)
(First)
(Middle)
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
Date of
File A -
Action
Decision
DD
or
OIC
Office
Complete and Submit Both Forms.
RET'D-TRANS.-OUT
RECEIVED
TRANS. IN
COMPLETED
Form I-212 (Rev. 10/26/05)Y
f
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