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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


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)


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



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 _______________________________

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