Uscis Form I-765 - Application For Employment Authorization
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1
2USCIS
Application For Employment Authorization
Form I-765
Department of Homeland Security
OMB No. 1615-0040
U.S. Citizenship and Immigration Services
Expires 02/28/2018
Action Block
Initial Receipt
Resubmitted
Fee Stamp
For
USCIS
Relocated
Use
Received
Sent
Only
Completed
Application Denied - Failed to establish:
Approved
Denied
Application Approved
Eligibility under
Economic necessity under
Authorization/Extension Valid From
8 CFR 274a.12
8 CFR 274a.12(c)(14), (18)
A#
(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.
9.
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).
10.
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
document).
11.
Have you ever before applied for employment
1.
Full Name
authorization from USCIS?
Family Name
First Name
Middle Name
Yes (Complete the following questions.)
Which USCIS Office?
Dates
2.
Other Names Used (include Maiden Name)
Family Name
First Name
Middle Name
Results (Granted or Denied - attach all documentation)
No (Proceed to Question 12.)
3.
U.S. Mailing Address
12.
Date of Last Entry into the U.S., on or about
Street Number and Name
Apt. Number
(mm/dd/yyyy)
Town or City
State
ZIP Code
13.
Place of Last Entry into the U.S.
4.
Country of Citizenship or Nationality
14.
Status at Last Entry (B-2 Visitor, F-1 Student, No Lawful
Status, etc.)
5.
Place of Birth
Town or City
State/Province
Country
15.
Current Immigration Status (Visitor, Student, etc.)
16. Eligibility Category. Go to the "Who May File Form
6.
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
7.
Gender
Male
Female
from the instructions. For example, (a)(8), (c)(17)(iii), etc.
8.
Marital Status
(
)
(
)
(
)
Single
Married
Divorced
Widowed
Page 1 of 2
Form I-765 01/17/17 N
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