I-765 Form

I-765 Application for Employment Authorization

This Application for Employment Authorization (I-765) is submitted by Applicant Name: whose U.S. mailing address is and who makes the statements and certifications set forth below. The receiving office or authorized recipient (Receiving Office Name:) is identified for processing purposes.

Recitals

WHEREAS, Applicant seeks authorization to be employed in the United States and submits this application to obtain Employment Authorization Document (EAD) benefits under applicable immigration statutes and regulations;

WHEREAS, Applicant declares under penalty of perjury that the information contained herein is true and correct to the best of Applicant's knowledge and that Applicant is eligible under the immigration classification indicated in this application;

WHEREAS, the Receiving Office will accept, review, and adjudicate this application in accordance with applicable laws, regulations, and internal procedures governing employment authorization.

NOW, THEREFORE, in consideration of the mutual representations and covenants herein, Applicant submits this Application and agrees to the terms and certifications set forth in the numbered sections below.

1. Eligibility Category

Select the eligibility category that applies. Applicant certifies that the category code entered is accurate and that Applicant retains documentation to substantiate eligibility.

2. Applicant Information

3. Additional Information

Have you previously filed Form I-765? Yes No

4. Applicant's Statement, Certification, and Authorization

By signing below, Applicant declares under penalty of perjury that the information contained in this application and accompanying documents is complete, true, and correct. Applicant understands that submission of false statements or fraudulent documents may result in denial of this application and may subject Applicant to civil and criminal penalties, including removal from the United States.

Applicant authorizes the Receiving Office and other designated government entities to verify the information provided, to obtain records relevant to the adjudication of this application, and to request and receive supplemental documentation where necessary. Applicant further authorizes any employer, school, or other person or entity in possession of relevant records to release such records to the Receiving Office upon request.

5. Notices and Service

All notices, requests for additional evidence, or decisions delivered in connection with this application shall be sent to the U.S. mailing address provided above unless Applicant provides a written alternate address. Applicant agrees to timely notify the Receiving Office of any change of address and acknowledges that failure to do so may result in delayed or missed communications.

6. Administrative Provisions

Governing Law: This application and any determinations made pursuant to it shall be governed by and construed in accordance with applicable federal immigration laws and regulations, and where applicable, relevant statutes governing administrative adjudication.

Entire Agreement: This application, together with attachments and supporting documents submitted in connection with it, constitutes the entire written record of Applicant's request for employment authorization and supersedes any prior written or oral statements made for the same purpose.

Severability: If any provision of this application is found to be invalid or unenforceable, the remainder of this application shall remain in full force and effect and shall be interpreted so as to give maximum effect to the original intent of the parties.

Amendments and Waiver: Any amendment to this application or waiver of any provision must be in writing and signed by Applicant and an authorized official of the Receiving Office. No failure or delay by the Receiving Office in exercising any right shall operate as a waiver thereof.

7. Declarations Regarding Representation

If Applicant is represented by an attorney or accredited representative, that representative must complete the Declaration of Representative and provide the appropriate written authorization. Applicant acknowledges responsibility for providing accurate representation information and for maintaining direct communication with the Receiving Office concerning this application.

Signature

Applicant attests, under penalty of perjury, that the statements and documentation submitted in support of this application are true, correct, and complete.

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