I-212, Application for Permission to Reapply for Admission Into the United States After Deportation or Removal (United States)
This form is to reapply for admission into the United States after deportation or removal. The form provided here is simply a sample of what the actual Form I-212 looks like.
Department of Homeland Security
U.S. Citizenship and Immigration Services
I-212, Application for Permission to Reapply for Admission Into the United States After Deportation or Removal
Date (mm/dd/yyyy) _______________________________
Fee Stamp _______________________________
I request permission to reapply for admission into the United States.
1. Name (Last) _______________________________
(First) _______________________________
(Middle) _______________________________
2. File numbers on correspondence from U.S. Citizenship and Immigration Services (USCIS) or former Immigration and Naturalization Service (INS) (if known) _______________________________
3. Name used when last deported or removed from the U.S. _______________________________
4. Date of Birth (mm/dd/yyyy) _______________________________
5. Other names used or known by _______________________________
6a. Place of Birth (city or town; state or province; and country) _______________________________
6b. Country of Citizenship/Nationality _______________________________
7. Circumstances under which deported or removed from the United States (Check applicable blocks)
____ Excluded and deported or removed. (less than one year ago)
____ Arrested and deported or removed. (less than five years ago)
____ Removed after having fallen into distress. (less than five years ago)
____ Removed as alien enemy (less than five years ago)
____ Removed at U.S. Government expense in lieu of deportation (less than five years ago)
8. Length of residence in the United States (years) _______________________________
9. Place of residence at time of deportation or removal from United States (city and state) _______________________________
10. Place deportation hearing held or application for removal made (city) _______________________________
11. Country to which deported or removed _______________________________
12. Detention facility or jail where detained (city and state) (If not detained, write "None") _______________________________
13. Date of deportation or removal from United States (mm/dd/yyyy) _______________________________
14. Port of departure from United States _______________________________
15. Status desired if permitted to re-enter United States
____ Permanent Resident
____ Visitor
____ Student
____ Other (specify) _______________________________
16. Reasons for desiring to re-enter the United States _______________________________
17. Location of American Embassy/Consulate where application for visa will be made (city and country) _______________________________
18. Name and relationship of U.S. citizen or lawful permanent resident alien spouse, parent or children, if any _______________________________
19. Signature of Applicant_______________________________
20. Street and number; city or town; state or province; and country of present residence _______________________________
Signature of person preparing form, if other than applicant
21. 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)
This space for use by DHS officer
---------------------------------
File A-_______________________________
Decision _____________________________
Admitted as _______________________________ (Nonimmigrant Class) until ____________________
____ Application disapproved.
-----------------------------
Date of Action _______________________________
DD or OIC Office _______________________________