OMB No. 1615-0040; Expires 02/28/2018
I-765, Application For
Department of Homeland Security
Employment Authorization
U.S. Citizenship and Immigration Services
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
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).
1.
Full Name
15.
Current Immigration Status (Visitor, Student, etc.)
H4
(Family Name)
(First Name)
(Middle Name)
Gupta
ABC
16.
Eligibility Category. Go to the “Who May File Form I-765?”
2.
Other Names Used (include Maiden Name)
section of the Instructions. In the space below, place the letter
and number of the eligibility category you selected from the
ABC Sharma
instructions. For example, (a)(8), (c)(17)(iii), etc.
3.
U.S. Mailing Address
C
26
(
)
(
)
(
)
(Street Number and Name)
(Apt. Number)
17.
(c)(3)(C) Eligibility Category. If you entered the eligibility
12 Glen Ave
12
category (c)(3)(C) in Question 16 above, list your degree, your
(Town or City)
(State)
(ZIP Code)
employer's name as listed in E-Verify, and your employer's
Boston
MA
01234
E-Verify Company Identification Number or a valid E-Verify
Client Company Identification Number in the space below.
4.
Country of Citizenship or Nationality
Degree
Employer's Name as listed in E-Verify
INDIA
5.
Place of Birth
Employer's E-Verify Company Identification Number or a Valid
(Town or City)
(State/Province)
(Country)
E-Verify Client Company Identification Number
DELHI
DELHI
INDIA
01/01/1980
6.
Date of Birth (mm/dd/yyyy)
18.
(c)(26) Eligibility Category. If you entered the eligibility
category (c)(26) in Question 16 above, please provide the receipt
7.
Gender
Male
Female
number of your H-1B principal spouse's most recent Form I-797
Notice of Approval for Form I-129.
8.
Marital Status
EAC-12-345-67890
Married
Single
Divorced
Widowed
Certification
9.
Social Security Number (Include all numbers you have ever
used, if any)
I certify, under penalty of perjury, that the foregoing is true and
123-45-6789
correct. Furthermore, I authorize the release of any information that
U.S. Citizenship and Immigration Services needs to determine
10.
Alien Registration Number (A-Number) or Form I-94 Number
eligibility for the benefit I am seeking. I have read the “Who May File
(if any)
Form I-765?” section of the instructions and have identified the
12345678910
appropriate eligibility category in Question 16.
11.
Have you ever before applied for employment authorization
Applicant's Signature
from USCIS?
05/25/2015
Date of Signature (mm/dd/yyyy)
Yes (Complete the following questions.)
(123) 456-7899
Telephone Number
Which USCIS Office?
Dates
Signature of Person Preparing Form, If Other Than Applicant
Results (Granted or Denied - attach all documentation)
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
No (Proceed to Question 12.)
knowledge.
12.
Date of Last Entry into the U.S., on or about (mm/dd/yyyy)
Preparer's Signature
01/13/2013
Date of Signature (mm/dd/yyyy)
13.
Place of Last Entry into the U.S.
Printed Name
Boston
Address
Status at Last Entry (B-2 Visitor, F-1 Student, No Lawful
14.
Status, etc.)
H4
Form I-765 03/11/16 Y