I-765, Application for Employment Authorization (United States)
I-765, Application for Employment Authorization (United States)
This form is to apply for employment in the United States. The form provided here is simply a sample of what the actual Form I-765 looks like.
Department of Homeland Security
U.S. Citizenship and Immigration Services
I-765, Application for Employment Authorization
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Do not write in this block.
Remarks _______________________________
A# _______________________________
Applicant is filing under ยง274a.12 _______
Action Block
Fee Stamp
____ Application Approved. Employment Authorized / Extended
(Circle One)
until _________________ (Date)
_________________ (Date)
Subject to the following conditions: _______________________________
____ Application Denied.
____ Failed to establish eligibility under 8 CFR 274a.12 (a) or (c).
____ Failed to establish economic necessity as required in 8 CFR 274a.12(c)(14), (18) and 8 CFR 214.2(f)
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I am applying for:
____ Permission to accept employment.
____ Replacement (of lost employment authorization document).
____ Renewal of my permission to accept employment
1. Name (Family Name in CAPS) _______________________________
(First) _______________________________
(Middle) _______________________________
2. Other Names Used (Include Maiden Name)
3. Address in the United States (Number and Name) _______________________________
(Apt. Number) _______________________________
(Town or City) _______________________________
(State/Country) _______________________________
(Zip Code) _______________________________
4. Country of Citizenship/Nationality _______________________________
5. Place of Birth (Town or City) _______________________________
(State/Province) _______________________________
(Country) (State/Country) _______________________________
6. Date of Birth (mm/dd/yyyy) _______________________________
7. Gender ____ Male ____ Female
8. Marital Status ____ Married ____ Widowed ____ Single ____ Divorced
9. Social Security Number (Include all numbers you have ever used) (if any) _______________________________
10. Alien Registration Number (A-Number) or I-94 Number (if any) _______________________________
11. Have you ever before applied for employment authorization from USCIS? ____ Yes (If yes, complete below) ____ No
Which USCIS Office? _______________________________
Date(s) _______________________________
Results (Granted or Denied - attach all documentation) _______________________________
12. Date of Last Entry into the U.S. (mm/dd/yyyy) _______________________________
13. Place of Last Entry into the U.S. _______________________________
14. Manner of Last Entry (Visitor, Student, etc.) _______________________________
15. Current Immigration Status (Visitor, Student, etc.)
16. Go to Part 2 of the Instructions, Eligibility Categories. In the space below, place the letter and number of the category you selected from the instructions (For example, (a)(8), (c)(17)(iii), etc.).
Eligibility under 8 CFR 274a.12
(_____________)(_____________)(_____________)
Certification.
Your certification. I certify, under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct. Furthermore, I authorize the release of any information that the U.S. Citizenship and Immigration Services needs to determine eligibility for the benefit I am seeking. I have read the Instructions in Part 2 and have identified the appropriate eligibility category in Block 16.
Signature _______________________________
Telephone Number _______________________________
Date _______________________________
Signature of Person Preparing Form, If Other Than Above: 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.
Print Name _______________________________
Address _______________________________
Signature _______________________________
Date _______________________________