Application For Employment Authorization
Department of Homeland Security
OMB No. 1615-0040
U.S. Citizenship and Immigration Services
Application Denied - Failed to establish:
Economic necessity under
Authorization/Extension Valid From
8 CFR 274a.12
8 CFR 274a.12(c)(14), (18)
(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.
Social Security Number (Include all numbers you have
I am applying for:
ever used, if any)
Permission to accept employment.
Replacement (of lost employment authorization document).
Alien Registration Number (A-Number) or Form I-94
Renewal of my permission to accept employment (attach a
Number (if any)
copy of your previous employment authorization
Have you ever before applied for employment
authorization from USCIS?
Yes (Complete the following questions.)
Which USCIS Office?
Other Names Used (include Maiden Name)
Results (Granted or Denied - attach all documentation)
No (Proceed to Question 12.)
U.S. Mailing Address
Date of Last Entry into the U.S., on or about
Street Number and Name
Town or City
Place of Last Entry into the U.S.
Country of Citizenship or Nationality
Status at Last Entry (B-2 Visitor, F-1 Student, No Lawful
Place of Birth
Town or City
Current Immigration Status (Visitor, Student, etc.)
16. Eligibility Category. Go to the "Who May File Form
Date of Birth (mm/dd/yyyy)
I-765?" section of the Instructions. In the space below, place
the letter and number of the eligibility category you selected
from the instructions. For example, (a)(8), (c)(17)(iii), etc.
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Form I-765 01/17/17 N