Fillable Uscis Form I-765 - Application For Employment Authorization printable pdf download

OMB No. 1615-0040; Expires 04/30/2016

I-765, Application For

Department of Homeland Security

Employment Authorization

U.S. Citizenship and Immigration Services

Do not write in this block.

Action Block

Fee Stamp

Remarks

Applicant is filing under §274a.12

Application Approved. Employment Authorized / Extended (Circle One)

until

(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 under 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 a copy of your previous employment authorization document).

Which USCIS Office?

Date(s)

1. Name (Family Name in CAPS) (First)

(Middle)

Results (Granted or Denied - attach all documentation)

2. Other Names Used (include Maiden Name)

12. Date of Last Entry into the U.S., on or about: (mm/dd/yyyy)

3. U.S. Mailing Address (Street Number and Name)

(Apt. Number)

13. Place of Last Entry into the U.S.

(Town or City)

(State/Country)

(ZIP Code)

14. Status at Last Entry (B-2 Visitor, F-1 Student, No Lawful Status, etc.)

4. Country of Citizenship/Nationality

15. Current Immigration Status (Visitor, Student, etc.)

5. Place of Birth (Town or City)

(State/Province)

(Country)

16. Go to the “Who May File Form I-765?” section of the instructions. In the

7. Gender

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

space below, place the letter and number of the eligibility category you

Male

Female

selected from the instructions. (For example, (a)(8), (c)(17)(iii), etc.).

8. Marital Status

Married

Single

)

(

)

(

Widowed

Divorced

9. Social Security Number (Include all numbers you have ever used, if any)

17. If you entered the eligibility category, (c)(3)(C), in Question 16 above, list your

degree, your employer's name as listed in E-Verify, and your employer's E-

Verify Company Identification Number or a valid E-Verify Client Company

10. Alien Registration Number (A-Number) or I-94 Number (if any)

Identification Number in the space below.

Degree:

The Research Foundation at State

University of New York at Binghamton

11. Have you ever before applied for employment authorization from USCIS?

Employer's Name as listed in E-Verify:

(Proceed to

Yes

(Complete the following

Employer's E-Verify Company Identification Number or a valid E-Verify

298797

questions.)

Question 12.)

Client Company Identification Number

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 that U.S. Citizenship and Immigration Services needs to 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 Question 16.

Signature

Telephone Number

Date

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

Initial Receipt

Resubmitted

Completed

Remarks

Approved

Returned

Received

Sent

Denied

Form I-765 08/06/14 Y

Uscis Form I-765 - Application For Employment Authorization

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