Application For Work Permit – Fill Out and Use This PDF

Part 1. Reason for Applying

I am applying for (select only one box):

1.a. 1.b.

1.c.

Part 2. Information About You

Your Full Legal Name

1.a. Family Name

(Last Name)

1.b. Given Name

(First Name)

1.c. Middle Name

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.

2.b.

2.c.

3.a.

3.b.

3.c.

4.a.

4.b.

4.c.

Part 2. Information About You (continued)

5.a. In Care Of Name (if any)

6.Is your current mailing address the same as your physical

Other Information

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

► A-

9.USCIS Online Account Number (if any)

►

11.Marital Status

12.Have you previously filed Form I-765?

Yes No

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

Yes No

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.

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

►

14.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.)

Yes No

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.

15.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

NOTE: If you answered “Yes” to Item Numbers

14.- 15., provide the information requested in Item Numbers 16.a. - 17.b.

Father's Name

Provide your father's birth name.

16.a. Family Name (Last Name)

16.b. Given Name (First Name)

Mother's Name

Provide your mother's birth name.

17.a. Family Name (Last Name)

17.b. Given Name (First 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.

18.a. Country

18.b. Country

Part 2. Information About You (continued)

Place of Birth

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

19.a. City/Town/Village of Birth

19.b. State/Province of Birth

19.c. Country of Birth

20. Date of Birth (mm/dd/yyyy)

Information About Your Last Arrival in the United States

21.a. Form I-94 Arrival-Departure Record Number (if any)

►

21.b. Passport Number of Your Most Recently Issued Passport

21.c. Travel Document Number (if any)

21.d. Country That Issued Your Passport or Travel Document

21.e. Expiration Date for Passport or Travel Document (mm/dd/yyyy)

22.Date of Your Last Arrival Into the United States, On or

About (mm/dd/yyyy)

23.Place of Your Last Arrival Into the United States

24.Immigration Status at Your Last Arrival (for example, B-2 visitor, F-1 student, or no status)

25.Your Current Immigration Status or Category (for example, B-2 visitor, F-1 student, parolee, deferred action, or no status or category)

26.Student and Exchange Visitor Information System (SEVIS) Number (if any)

►N-

Information About Your Eligibility Category

27.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)).

28.(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.a. Degree

28.b. Employer's Name as Listed in E-Verify

28.c. Employer's E-Verify Company Identification Number or a Valid E-Verify Client Company Identification Number

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.

►

30.(c)(8) Eligibility Category If you entered the eligibility category (c)(8) in Item Number 27., provide the information requested in Item Numbers 30.a. - 30.g.

30.a. Have you EVER been arrested for, and/or charged with, and/or convicted of any crime in any country?

Yes No

NOTE: If you answered “Yes” to Item Number 30.a., refer to Special Filing Instructions for Those With Pending Asylum Applications (c)(8) of the Form I-765 Instructions for information about providing court dispositions.

30.b. Did you enter the United States lawfully through a U.S. port of entry and were you inspected and admitted or paroled after inspection by an immigration officer? (If you answer “Yes,” you MUST provide evidence of your lawful entry.)

30.c. If you answered “No” to Item Number 30.b., did you present yourself to the Secretary of Homeland Security or his or her delegate (DHS) within 48 hours of entry or attempted entry AND express an intention to seek asylum within the United States or express a fear of persecution

Part 2. Information About You (continued)

If you answered “Yes” to Item Number 30.c., provide the following information:

30.d. Date you presented yourself to DHS

30.e. Location where you presented yourself to DHS

30.f. Country of claimed persecution

30.g. Provide an explanation for why you did not enter the United States lawfully through a U.S. port of entry. If you need extra space to complete this item, use the space provided in Part 6. Additional Information.

NOTE: Refer to the Special Filing Instructions for Those With Pending Asylum Applications (c)(8) section of the Form

I-765 Instructions for more information.

31.a. (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.b. If you entered the eligibility category (c)(35) or (c)(36) in Item Number 27., have you EVER been arrested for

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.

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

NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2.

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.

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 Contact Information

3.Applicant's Daytime Telephone Number

4.Applicant's Mobile Telephone Number (if any)

5.Applicant's Email Address (if any)

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

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.

Part 3. Applicant's Statement, Contact

Information, Declaration, Certification, and

Signature (continued)

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

7.a. Applicant's Signature

7.b. Date of Signature (mm/dd/yyyy)

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 Mailing Address

Interpreter's Contact Information

4.Interpreter's Daytime Telephone Number

5.Interpreter's Mobile Telephone Number (if any)

6.Interpreter's Email Address (if any)

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

Provide the following information about the interpreter.

Interpreter's Full Name

1.a. Interpreter's Family Name (Last Name)

1.b. Interpreter's Given Name (First Name)

2.Interpreter's Business or Organization Name (if any)

Interpreter's Certification

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.

Interpreter's Signature

7.a. Interpreter's Signature

7.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

Provide the following information about the preparer.

Preparer's Full Name

1.a. Preparer's Family Name (Last Name)

1.b. Preparer's Given Name (First Name)

2.Preparer's Business or Organization Name (if any)

Preparer's Mailing Address

Preparer's Contact Information

4.Preparer's Daytime Telephone Number

5.Preparer's Mobile Telephone Number (if any)

6.Preparer's Email Address (if any)

Preparer's Statement

NOTE: If you are an attorney or accredited representative, you 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

8.a. Preparer's Signature

8.b. Date of Signature (mm/dd/yyyy)

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.

4.a. Page Number 4.b. Part Number 4.c. Item Number

4.d.

5.a. Page Number 5.b. Part Number 5.c. Item Number

5.d.

6.a. Page Number 6.b. Part Number 6.c. Item Number

6.d.

7.a. Page Number 7.b. Part Number 7.c. Item Number

7.d.