I 765 Form – Fill Out and Use This PDF

Part 1. Reason for Applying: I am applying for (select only one box): 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.

Replacement (correction) of an employment authorization document due to USCIS error does not require a new Form I-765 and filing fee. Refer to www.uscis.gov/i-765 for further details.

Renewal of my permission to accept employment: attach a copy of your previous employment authorization document.

To be completed by an Attorney or Accredited Representative (if any): select this box if Form G-28 is attached.

Your Full Legal Name: enter 1.a. Family Name (Last Name), 1.b. Given Name (First Name) and 1.c. Middle Name.

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.

Your U.S. Mailing Address: enter In Care Of Name (if any) 5.a., Street Number and Name 5.b., Ste. Flr. Apt. 5.c., City or Town 5.d., State 5.e. and ZIP Code 5.f.

Is your current mailing address the same as your physical address? No or Yes.

If you answered “No” to Item Number 6., provide your U.S. Physical Address.

Alien Registration Number (A-Number) (if any).

USCIS Online Account Number (if any).

Sex: Female or Male.

Marital Status: Widowed, Divorced, Single or Married.

Have you previously filed Form I-765? No or Yes.

Provide your Social Security number (SSN) (if known).

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.

Place of Birth: List the city/town/village, state/province, and country where you were born.

Date of Birth (mm/dd/yyyy).

Information About Your Last Arrival in the United States: enter the Form I-94 Arrival-Departure Record Number (if any), the Passport Number of Your Most Recently Issued Passport and the Travel Document Number (if any).

Country That Issued Your Passport or Travel Document, and Expiration Date for Passport or Travel Document (mm/dd/yyyy).

Date of Your Last Arrival Into the United States, On or About (mm/dd/yyyy), and 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: 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 (for example, (a)(8), (c)(17)(iii)).

NOTE: Read the Penalties section of the Form I-765 Instructions before completing this section.

Part 3. Applicant's Statement, Contact Information, Certification, and Signature: Select the box for either Item Number 1.a. or 1.b. Item Number 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.

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 in which I am fluent, and I understood everything.

If applicable, select the box for Item Number 2. At my request, the preparer named in Part 5., prepared this application for me based only upon information I provided or authorized.

Select this box if you are a Salvadoran or Guatemalan national eligible for benefits under the ABC settlement agreement.

Applicant's Contact Information: enter the Applicant's Daytime Telephone Number, Applicant's Mobile Telephone Number (if any) and Applicant's Email Address (if any).

Applicant's Certification: "I certify, under penalty of perjury, that I provided or authorized all of the information in my application, I 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 and Date of Signature (mm/dd/yyyy).

(c)(35) or (c)(36) Eligibility Category: 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? 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.

(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: Degree, Employer's Name as Listed in E-Verify, and Employer's E-Verify Company Identification Number or a Valid E-Verify Client Company Identification Number.

(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? 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.

Part 4. Interpreter's Contact Information, Certification, and Signature: Provide the following information about the interpreter: Interpreter's Full Name, Interpreter's Family Name (Last Name) 1.a., Interpreter's Given Name (First Name) 1.b. and Interpreter's Business or Organization Name (if any) 2.

Interpreter's Signature and Date of Signature (mm/dd/yyyy).

Part 5. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other Than the Applicant: Provide the following information about the preparer: Preparer's Full Name, 1.a. Preparer's Family Name (Last Name) and Preparer's Given Name (First Name) 1.b.

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 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 Signature and Date of Signature (mm/dd/yyyy).

You must file Form I-765 while in the United States. START HERE - Type or print in black ink.

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.

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 provided or authorized all of the information in my application; and 2) I understood all of the information contained in, and submitted with, my application; and 3) All of this information was complete, true, and correct at the time of filing.