Page 1 of 7Form I-765 05/31/18
Authorization/Extension
Valid Through
Authorization/Extension
Valid From
For
USCIS
Use
Only
Application For Employment Authorization
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-765
OMB No. 1615-0040
Expires 05/31/2020
START HERE - Type or print in black ink.►
Part 1. Reason for Applying
Your Full Legal Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
Initial permission to accept employment.
I am applying for (select only one box):
Replacement of lost, stolen, or damaged employment
authorization document, or correction of my
employment authorization document NOT DUE to
U.S. Citizenship and Immigration Services (USCIS)
error.
NOTE: Replacement (correction) of an employment
authorization document due to USCIS error does not
require a new Form I-765 and filing fee. Refer to
Replacement for Card Error in the What is the
Filing Fee section of the Form I-765 Instructions for
further details.
1.a.
1.b.
Renewal of my permission to accept employment.
(Attach a copy of your previous employment
authorization document.)
1.c.
Action BlockFee Stamp
Select this box if Form G-28
is attached.
Attorney or Accredited Representative
USCIS Online Account Number (if any)
To be completed by an attorney or
Board of Immigration Appeals (BIA)-
accredited representative (if any).
Part 2. Information About You
Other Names Used
Provide all other names you have ever used, including aliases,
maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 6.
Additional Information.
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Middle Name
3.a.
Middle Name4.c.
Given Name
(First Name)
4.b.
Family Name
(Last Name)
4.a.
Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name
Remarks
A-
Alien Registration Number
Page 2 of 7Form I-765 05/31/18
Part 2. Information About You (continued)
NoYes
Is your current mailing address the same as your physical
address?
6.
NOTE: If you answered “No” to Item Number 6.,
provide your physical address below.
U.S. Physical Address
7.c. City or Town
7.d. State 7.e. ZIP Code
7.b.
Ste. Flr.
Apt.
7.a.
Street Number
and Name
Other Information
USCIS Online Account Number (if any)9.
►
►
A-
8. Alien Registration Number (A-Number) (if any)
Consent for Disclosure: I authorize disclosure of
information from this application to the SSA as required
for the purpose of assigning me an SSN and issuing me a
Social Security card.
15.
NoYes
NOTE: If you answered “Yes” to Item Numbers
14. - 15., provide the information requested in Item
Numbers 16.a. - 17.b.
FemaleMaleGender10.
WidowedDivorcedSingle Married
Marital Status
11.
12. Have you previously filed Form I-765?
No
Yes
Father's Name
16.a. Family Name
(Last Name)
16.b. Given Name
(First Name)
Mother's Name
17.a. Family Name
(Last Name)
17.b. Given Name
(First Name)
Provide your mother's birth name.
Provide your father's birth name.
List all countries where you are currently a citizen or national.
If you need extra space to complete this item, use the space
provided in Part 6. Additional Information.
18.a.
Country18.b.
Country
Your Country or Countries of Citizenship or
Nationality
Do you want the SSA to issue you a Social Security card?
(You must also answer “Yes” to Item Number 15.,
Consent for Disclosure, to receive a card.)
14.
NoYes
NOTE: If you answered “No” to Item Number 14., skip
to Part 2., Item Number 18.a. If you answered “Yes” to
Item Number 14., you must also answer “Yes” to Item
Number 15.
Provide your Social Security number (SSN) (if known).13.b.
►
Your U.S. Mailing Address
5.d. City or Town
5.e. State 5.f. ZIP Code
5.c.
Ste. Flr.
Apt.
5.b.
In Care Of Name (if any)5.a.
Street Number
and Name
(USPS ZIP Code Lookup)
Has the Social Security Administration (SSA) ever
officially issued a Social Security card to you?
NoYes
13.a.
NOTE: If you answered “No” to Item Number 13.a.,
skip to Item Number 14. If you answered “Yes” to Item
Number 13.a., provide the information requested in Item
Number 13.b.
Page 3 of 7Form I-765 05/31/18
Part 2. Information About You (continued)
Travel Document Number (if any)21.c.
23. Place of Your Last Arrival Into the United States
Date of Your Last Arrival Into the United States, On or
About (mm/dd/yyyy)
22.
21.d.
Country That Issued Your Passport or Travel Document
21.e.
Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
Passport Number of Your Most Recently Issued Passport
21.b.
Immigration Status at Your Last Arrival (for example,
B-2 visitor, F-1 student, or no status)
24.
Your Current Immigration Status or Category (for example,
B-2 visitor, F-1 student, parolee, deferred action, or no
status or category)
25.
Student and Exchange Visitor Information System
(SEVIS) Number (if any)
26.
Employer's Name as Listed in E-Verify28.b.
Employer's E-Verify Company Identification Number or a
Valid E-Verify Client Company Identification Number
28.c.
29. (c)(26) Eligibility Category. If you entered the eligibility
category (c)(26) in Item Number 27., provide the receipt
number of your H-1B spouse's most recent Form I-797
Notice for Form I-129, Petition for a Nonimmigrant
Worker.
(c)(8) Eligibility Category. If you entered the eligibility
category (c)(8) in Item Number 27., have you EVER
been arrested for and/or convicted of any crime?
30.
Yes
NOTE: If you answered “Yes” to Item Number 30.,
refer to Special Filing Instructions for Those With
Pending Asylum Applications (c)(8) in the Required
Documentation section of the Form I-765 Instructions
for information about providing court dispositions.
No
►
►
(c)(35) and (c)(36) Eligibility Category. If you entered
the eligibility category (c)(35) in Item Number 27., please
provide the receipt number of your Form I-797 Notice for
Form I-140, Immigrant Petition for Alien Worker. If you
entered the eligibility category (c)(36) in Item Number
27., please provide the receipt number of your spouse's or
parent's Form I-797 Notice for Form I-140.
31.a.
Degree28.a.
Information About Your Last Arrival in the
United States
Form I-94 Arrival-Departure Record Number (if any)
►
21.a.
(c)(3)(C) STEM OPT Eligibility Category. If you
entered the eligibility category (c)(3)(C) in Item Number
27., provide the information requested in Item Numbers
28.a - 28.c.
28.
Eligibility Category. Refer to the Who May File Form
I-765 section of the Form I-765 Instructions to determine
the appropriate eligibility category for this application.
Enter the appropriate letter and number for your eligibility
category below (for example, (a)(8), (c)(17)(iii)).
27.
Information About Your Eligibility Category
Date of Birth (mm/dd/yyyy)20.
Country of Birth19.c.
19.a.
City/Town/Village of Birth
State/Province of Birth 19.b.
List the city/town/village, state/province, and country where
you were born.
Place of Birth
( ) )( )(
NOTE: If you answered “Yes” to Item Number 31.b.,
refer to Employment-Based Nonimmigrant Categories,
Items 8. - 9., in the Who May File Form I-765 section
of the Form I-765 Instructions for information about
providing court dispositions.
If you entered the eligibility category (c)(35) or (c)(36) in
Item Number 27., have you EVER been arrested for
and/or convicted of any crime?
Yes No
31.b.
►
N-
Page 4 of 7Form I-765 05/31/18
The interpreter named in Part 4. read to me every
question and instruction on this application and my
answer to every question in
1.b.
I can read and understand English, and I have read
and understand every question and instruction on this
application and my answer to every question.
1.a.
a language in which I am fluent, and I understood
everything.
,
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
Part 3. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature
Applicant's Statement
NOTE: Read the Penalties section of the Form I-765
Instructions before completing this section. You must file
Form I-765 while in the United States.
2.
At my request, the preparer named in Part 5.,
prepared this application for me based only upon
information I provided or authorized.
,
Applicant's Declaration and Certification
Copies of any documents I have submitted are exact photocopies
of unaltered, original documents, and I understand that USCIS
may require that I submit original documents to USCIS at a later
date. Furthermore, I authorize the release of any information
from any and all of my records that USCIS may need to
determine my eligibility for the immigration benefit that I seek.
I furthermore authorize release of information contained in this
application, in supporting documents, and in my USCIS
records, to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
I understand that USCIS may require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, if I am required to provide
biometrics, I will be required to sign an oath reaffirming that:
1) I reviewed and understood all of the information
contained in, and submitted with, my application; and
2) All of this information was complete, true, and correct
at the time of filing.
I certify, under penalty of perjury, that all of the information in
my application and any document submitted with it were
provided or authorized by me, that I reviewed and understand
all of the information contained in, and submitted with, my
application and that all of this information is complete, true, and
correct.
Applicant's Signature
Date of Signature (mm/dd/yyyy)7.b.
Applicant's Signature7.a.
NOTE TO ALL APPLICANTS: If you do not completely fill
out this application or fail to submit required documents listed
in the Instructions, USCIS may deny your application.
Applicant's Daytime Telephone Number3.
Applicant's Contact Information
Applicant's Mobile Telephone Number (if any)4.
Applicant's Email Address (if any)5.
Select this box if you are a Salvadoran or Guatemalan
national eligible for benefits under the ABC
settlement agreement.
6.
Part 4. Interpreter's Contact Information,
Certification, and Signature
Interpreter's Business or Organization Name (if any)
2.
Interpreter's Given Name (First Name)1.b.
Interpreter's Family Name (Last Name)1.a.
Interpreter's Full Name
Provide the following information about the interpreter.
Page 5 of 7Form I-765 05/31/18
Interpreter's Contact Information
Interpreter's Daytime Telephone Number4.
Interpreter's Email Address (if any)6.
Interpreter's Mobile Telephone Number (if any)
5.
Interpreter's Certification
I am fluent in English and
which is the same language specified in Part 3., Item Number
1.b., and I have read to this applicant in the identified language
every question and instruction on this application and his or her
answer to every question. The applicant informed me that he or
she understands every instruction, question, and answer on the
application, including the Applicant's Declaration and
Certification, and has verified the accuracy of every answer.
I certify, under penalty of perjury, that:
,
Preparer's Given Name (First Name)1.b.
2. Preparer's Business or Organization Name (if any)
Preparer's Full Name
Provide the following information about the preparer.
1.a. Preparer's Family Name (Last Name)
Part 5. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, If Other Than the Applicant
Preparer's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f.
Postal Code
Street Number
and Name
3.a.
3.b. Flr.Apt.
Ste.
3.g.
3.h. Country
Province
Preparer's Contact Information
Preparer's Mobile Telephone Number (if any)5.
Preparer's Daytime Telephone Number4.
Preparer's Email Address (if any)6.
Interpreter's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f.
Postal Code
Street Number
and Name
3.a.
3.b. Flr.Apt.
Ste.
3.g.
3.h. Country
Province
Part 4. Interpreter's Contact Information,
Certification, and Signature
Interpreter's Signature
Date of Signature (mm/dd/yyyy)7.b.
Interpreter's Signature
7.a.
Page 6 of 7Form I-765 05/31/18
Preparer's Statement
I am not an attorney or accredited representative
but have prepared this application on behalf of
the applicant and with the applicant's consent.
NOTE: If you are an attorney or accredited ay
need to submit a completed Form G-28, Notice
of Entry of Appearance as Attorney or
Accredited Representative, with this application.
I am an attorney or accredited representative and
my representation of the applicant in this case
extends does not extend beyond the
7.a.
7.b.
preparation of this application.
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
prepared this application at the request of the applicant. The
applicant then reviewed this completed application and
informed me that he or she understands all of the information
contained in, and submitted with, his or her application,
including the Applicant's Declaration and Certification, and
that all of this information is complete, true, and correct. I
completed this application based only on information that the
applicant provided to me or authorized me to obtain or use.
Preparer's Signature
8.a.
Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
Part 5. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, If Other Than the Applicant
(continued)
Page 7 of 7Form I-765 05/31/18
Part 6. Additional Information
If you need extra space to provide any additional information
within this application, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this application or attach a separate
sheet of paper. Type or print your name and A-Number (if any)
at the top of each sheet; indicate the Page Number, Part
Number, and Item Number to which your answer refers; and
sign and date each sheet.
A-Number (if any) ►
A-
3.a.
2.
Page Number 3.b. Part Number 3.c. Item Number
3.d.
Page Number Part Number Item Number
Page Number Part Number Item Number5.a.
Page Number
5.b.
Part Number
5.c.
Item Number
5.d.
Part NumberPage Number Item Number
1.b.
1.c.
1.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
4.c.4.b.
4.d.
4.a.
6.d.
6.c.6.b.6.a.
7.c.7.b.7.a.
7.d.
