Page 1 of 7 Form I-765 Edition 04/01/24 

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 02/28/2027

► 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.

Fee Stamp Action Block

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.

4.c. Middle Name

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

Alien Registration Number A-
Page 2 of 7 Form I-765 Edition 04/01/24 

Part 2. Information About You (continued)

Yes No

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. Apt. Ste. Flr.

7.a. Street Number 

and Name

Other Information

9. USCIS Online Account Number (if any)

►

► A8. 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.

Yes No

NOTE: If you answered “Yes” to Item Numbers 

14. - 15., provide the information requested in Item 

Numbers 16.a. - 17.b.

10. Gender Male Female

Single Married Divorced Widowed

11. Marital Status

12. Have you previously filed Form I-765? 

Yes No

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.

18.b. Country

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.

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.

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

►

Your U.S. Mailing Address

5.d. City or Town

5.e. State 5.f. ZIP Code

5.c. Apt. Ste. Flr.

5.b.

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

Street Number 

and Name

(USPS ZIP Code Lookup)

Has the Social Security Administration (SSA) ever 

officially issued a Social Security card to you? 

Yes No

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 7 Form I-765 Edition 04/01/24 

Part 2. Information About You (continued)

21.c. Travel Document Number (if any)

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)

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

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.

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

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.

28.a. Degree

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

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

19.c. Country of Birth

19.a. City/Town/Village of Birth 

19.b. State/Province of Birth 

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 7 Form I-765 Edition 04/01/24 

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

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

7.a. Applicant's Signature

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.

3. Applicant's Daytime Telephone Number

Applicant's Contact Information

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

5. Applicant's Email Address (if any)

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 

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

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

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

Interpreter's Full Name

Provide the following information about the interpreter.
Page 5 of 7 Form I-765 Edition 04/01/24 

Interpreter's Contact Information

4. Interpreter's Daytime Telephone Number

6. Interpreter's Email Address (if any)

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

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:

,

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

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. Apt. Ste. Flr.

3.g.

3.h. Country 

Province

Preparer's Contact Information

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

4. Preparer's Daytime Telephone Number

6. Preparer's Email Address (if any)

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. Apt. Ste. Flr.

3.g.

3.h. Country 

Province

Part 4. Interpreter's Contact Information, 

Certification, and Signature 

Interpreter's Signature

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

7.a. Interpreter's Signature
Page 6 of 7 Form I-765 Edition 04/01/24 

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 

representative, you may 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 7 Form I-765 Edition 04/01/24 

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) ►A3.a.

2.

Page Number 3.b. Part Number 3.c. Item Number

3.d.

Page Number Part Number Item Number

5.a. Page Number Part Number Item Number

Page Number

5.b.

Part Number

5.c.

Item Number

5.d.

Page Number Part Number Item Number

1.b. 

1.c.

1.a. Family Name 

(Last Name) 

Given Name 

(First Name) 

Middle Name

4.b. 4.c.

4.d.

4.a.

6.d.

6.a. 6.b. 6.c.

7.a. 7.b. 7.c.

7.d.