Uscis Form I-765 - Application For Employment Authorization Page 2
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217.
(c)(3)(C) Eligibility Category. If you entered the
Certification
eligibility category (c)(3)(C) in Question 16 above, list
I certify, under penalty of perjury, that the foregoing is true and
your degree, your employer's name as listed in E-Verify,
correct. Furthermore, I authorize the release of any information
and your employer's E-Verify Company Identification
that U.S. Citizenship and Immigration Services needs to
Number or a valid E-Verify Client Company Identification
determine eligibility for the benefit I am seeking. I have read
Number in the space below.
the “Who May File Form I-765?” section of the instructions
Degree
Employer's Name as listed in E-Verify
and have identified the appropriate eligibility category in
Question 16.
Applicant's Signature
Employer's E-Verify Company Identification Number or a
Valid E-Verify Client Company Identification Number
Date of Signature (mm/dd/yyyy)
18.
(c)(26) Eligibility Category. If you entered the eligibility
Telephone Number
category (c)(26) in Question 16 above, please provide the
receipt number of your H-1B principal spouse's most recent
Form I-797 Notice of Approval for Form I-129.
Signature of Person Preparing Form, If Other Than
Applicant
19. (c)(35) and (c)(36) Eligibility Category
I declare that this document was prepared by me at the request
a.
If you entered the eligibility category (c)(35) or (c)(36)
of the applicant and is based on all information of which I have
in Question 16 above, please provide the receipt
any knowledge.
number of the Form I-140 beneficiary's Form I-797
Preparer's Signature
Notice of Approval for Form I-140.
Date of Signature (mm/dd/yyyy)
b. Have you EVER been arrested for and/or convicted of
any crime?
Yes
No
Printed Name
NOTE: If you answered "Yes" to Item Numbers 19.b.,
refer to Item Number 5., Item H. or Item I. in the Who
May File Form I-765 section of these Instructions for
Address
information about providing court dispositions.
Page 2 of 2
Form I-765 01/17/17 N
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