I-765, Application for Employment Authorization

I-765, Application for Employment Authorization
Do you have an attorney or Board of Immigration Appeals accredited representative?*

YesNo
To be completed by applicant's attorney or Board of Immigration Appeals accredited representative

Note: Your attorney or Board of Immigration Appeals accredited representative needs to answer the following two questions.
Attorney or BIA, Please select this box if Form G-28 is attached

Form G-28 is attached
Attorney or BIA, Please Enter Your USCIS Online Account Number (if any)
Part 1. Reason for Applying
Reason for Applying for Employment Authorization*

Initial permission to accept employment.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.Renewal of my permission to accept employment.(Attach a copy of your previous employment authorization document.)
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.
Part 2. Information About You
Your Full Legal Name*

Given Name (First Name)Family Name (Last Name)
Middle Name
Middle Name
Do you currently use, or have you ever used, any other names?

YesNo
Other Names Used

Given Name (First Name)Middle NameFamily Name (Last Name)
Given Name (First Name)Middle NameFamily Name (Last Name)
Given Name (First Name)Middle NameFamily Name (Last Name)
In Care of Name (if any)

First NameLast Name
Your US Mailing Address*

Street Number and Name

Street Address Line 2

CityState

Zip Code
Apt/Suite/Floor

AptSuiteFloor
Apt/Suite/Floor Number
Is your current mailing address the same as your physical address?*

YesNo
Provide Your Physical Address*

Street Number and Name

Street Address Line 2

CityState

Zip Code
Apt/Suite/Floor

AptSuiteFloor
Apt/Suite/Floor Number
Alien Registration Number (A-Number) (if any)
A-Number
USCIS Online Account Number (if any)
USCIS Online Account Number
Sex*

MaleFemale
Marital Status*

SingleMarriedDivorcedWidowed
Have you previously filed Form I-765?*

YesNo
Has the Social Security Administration (SSA) ever officially issued a Social Security card to you?*

YesNo
Provide your Social Security number (SSN) (if known).*
SSN Number
Do you want the SSA to issue you a Social Security card?*

YesNo
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.*

YesNo
Father's Name*

Given Name (First Name)Family Name (Last Name)
Mother's Name*

Given Name (First Name)Family Name (Last Name)
Your Country or Countries of Citizenship or Nationality
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.
Country 1*
Country of Citizenship 1
Country 2
Country of Citizenship 2
Place of Birth
City/Town/Village of Birth*
City/Town/Village of Birth
State/Province of Birth*
State/Province of Birth
Country of Birth*
Country of Birth
Date of Birth*

MonthDayYear
Information About Your Last Arrival in the United States
Form I-94 Arrival-Departure Record Number (if any)
I-94 Record Number
Passport Number of Your Most Recently Issued Passport*
Passport Number
Travel Document Number (if any)
Travel Document Number
Country That Issued Your Passport or Travel Document*
Expiration Date for Passport or Travel Document*

MonthDayYear
Date of Your Last Arrival Into the United States, On or About*

MonthDayYear
Place of Your Last Arrival Into the United States*
Immigration Status at Your Last Arrival (for example, B-2 visitor, F-1 student, or no status)*
Your Current Immigration Status or Category (for example, B-2 visitor, F-1 student, parolee, deferred action, or no status or category)*
Student and Exchange Visitor Information System(SEVIS) Number (if any)
Information About Your Eligibility Category

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)). Form I-765 Instructions can be found at: https://www.uscis.gov/sites/default/files/document/forms/i-765instr.pdf
(1)*
Eligibility Category-Part 1
(2)*
Eligibility Category-Part 2
(3)
Eligibility Category-Part 3
Did you enter the eligibility category (c)(3)(C)?*

YesNo
Degree*
Degree
Employer's Name as Listed in E-Verify*
Employer's E-Verify Company Identification Number or a Valid E-Verify Client Company Identification Number*
Did you enter the eligibility category (c)(26)?*

YesNo
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.*
Did you enter the eligibility category (c)(8)?*

YesNo
Have you EVER been arrested for and/or convicted of any crime?

YesNo
NOTE:

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.
Did you enter the eligibility category (c)(35)?*

YesNo
Provide the receipt number of your Form I-797 Notice for Form I-140, Immigrant Petition for Alien Worker.
Did you enter the eligibility category (c)(36)?*

YesNo
Provide the receipt number of your spouse's or parent's Form I-797 Notice for Form I-140.
Have you EVER been arrested for and/or convicted of any crime?*

YesNo
NOTE:

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.
Part 3. Applicant's Statement, Contact Information, Declaration, Certification, and Signature

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.
Applicant's Statement
3.1.a - 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.

YesNo
3.1.b - The interpreter named in Part 4. read to me every question and instruction on this application and my answer to every question in a language (specified below) in which I am fluent, and I understood everything.

YesNo
SPECIFY THE LANGUAGE.*
The interpreter named in Part 4
At my request, the preparer named in Part 5. (specified below), prepared this application for me based only upon information I provided or authorized.

YesNo
PREPARER NAMED IN PART 5*
The preparer named in Part 5
Applicant's Contact Information
Applicant's Daytime Telephone Number*
Please enter a valid phone number.
Applicant's Mobile Telephone Number (if any)
Please enter a valid phone number.
Applicant's Email Address (if any)
example@example.com
Are you a Salvadoran or Guatemalan national eligible for benefits under the ABCsettlement agreement?*

YesNo
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*

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Date of Signature (mm/dd/yyyy)*

MonthDayYear
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.
Part 4. Interpreter's Contact Information, Certification, and Signature
Interpreter's Family Name (Last Name)
Interpreter's Given Name (First Name)
Interpreter's Business or Organization Name (if any)
Interpreter's Mailing Address*

Street Number and Name

Street Address Line 2

City or TownState

Zip Code
Apt/Suite/Floor

AptSuiteFloor
Apt/Suite/Floor Number
Province
Province
Postal Code
Postal Code
Country
Country
Interpreter's Daytime Telephone Number
Please enter a valid phone number.
Interpreter's Mobile Telephone Number (if any)
Please enter a valid phone number.
Email
example@example.com
Interpreter's Certification
I certify, under penalty of perjury, that:

I am fluent in English and the language specified below 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 am fluent in English and the language specified here
Interpreter's Signature

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Date of Signature (mm/dd/yyyy)

MonthDayYear
Part 5. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other Than the Applicant
Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)
Preparer's Business or Organization Name (if any)
Preparer's Mailing Address*

Street Number and Name

Street Address Line 2

City or TownState

Zip Code
Apt/Suite/Floor

AptSuiteFloor
Apt/Suite/Floor Number
Province
Province
Postal Code
Postal Code
Country
Country
Preparer's Daytime Telephone Number
Please enter a valid phone number.
Preparer's Mobile Telephone Number (if any)
Please enter a valid phone number.
Preparer's Email Address (if any)
example@example.com
Preparer's Statement
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.I am an attorney or accredited representative and my representation of the applicant in this case
I am an attorney or accredited representative and my representation of the applicant in this case:

Extends beyond the preparation of this application.Does not extend beyond the preparation of this application.
NOTE: If you are an attorney or accredited representative, you may need to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with 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

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Date of Signature (mm/dd/yyyy)

MonthDayYear
Recipient Organization
Recipient Email Address*

Confirmation Emailexample@example.com
Please verify that you are human*
Should be Empty:

I-765, Application for Employment Authorization

To be completed by applicant's attorney or Board of Immigration Appeals accredited representative

Part 1. Reason for Applying

Part 2. Information About You

Your Country or Countries of Citizenship or Nationality

Place of Birth

Information About Your Last Arrival in the United States

Information About Your Eligibility Category

Part 3. Applicant's Statement, Contact Information, Declaration, Certification, and Signature

Applicant's Statement

Applicant's Contact Information

Applicant's Declaration and Certification

Part 4. Interpreter's Contact Information, Certification, and Signature

Interpreter's Certification

Part 5. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other Than the Applicant

Preparer's Statement

Preparer's Certification