Immigration I-765 Application

IMMIGRATION APPLICATION FOR EMPLOYMENT AUTHORIZATION (I-765)

Applicant Name: Alien Registration Number (A-Number): Representative/Attorney Name:

RECITALS

WHEREAS, the Applicant seeks authorization to accept employment in the United States pursuant to immigration status, eligibility classification, and governing statutes and regulations governing employment authorization;

WHEREAS, the Applicant submits this application and supporting documentation under penalty of perjury and in accordance with the instructions and attestations contained herein;

WHEREAS, the Representative named above is authorized by the Applicant to assist in preparation and submission of this application and to receive correspondence related to this Application for Employment Authorization;

NOW, THEREFORE, the Applicant hereby submits the following information, certifies the truth of all statements and representations made below, and requests that employment authorization be granted as set forth in this application.

1. REQUESTED ACTION / ELIGIBILITY

Select the reason for filing this application:

2. APPLICANT INFORMATION

Date of Birth: Month Day Year

Country/Region of Birth: Country/Region of Citizenship/Nationality:

3. IMMIGRATION AND TRAVEL INFORMATION

Date of Last Arrival in the United States: Month Day Year

4. PREVIOUS AUTHORIZATIONS AND LIMITATIONS

5. SUPPORTING STATEMENT AND CERTIFICATION

I certify, under penalty of perjury under applicable federal law, that I am the person named in this application; that I have read and understand the statements contained herein; that all information submitted in support of this application is true and correct to the best of my knowledge; and that I will provide additional evidence upon request. I understand that false statements or willful misrepresentations may subject me to criminal, civil, or administrative penalties including denial of the application and removal from the United States.

6. REPRESENTATIVE INFORMATION (IF APPLICABLE)

7. NOTICES, WAIVERS, AND MISCELLANEOUS

Notices. All official correspondence relating to this application shall be sent to the U.S. mailing address provided above unless the Applicant designates, in writing, an alternate address or the Representative is expressly authorized to receive correspondence on the Applicant's behalf.

Amendments; Waiver. Any amendment to this application or its exhibits must be made in writing and signed by the Applicant. No waiver of any provision of this application shall be effective unless in writing and signed by the waiving party.

Governing Law. This application and any determinations made pursuant to it shall be governed by federal immigration law and applicable federal regulations. Where federal law is silent, applicable state law may apply only to the extent not inconsistent with federal law.

Entire Agreement. This document, together with any attachments, constitutes the entire statement of facts and requests made by the Applicant for employment authorization and supersedes any prior oral or written statements on the same subject.

Severability. If any provision of this application is held to be invalid, illegal, or unenforceable, the remaining provisions shall continue in full force and effect.

8. ADDITIONAL INFORMATION

ATTESTATION AND SIGNATURE

By signing below, the Applicant certifies under penalty of perjury that all information in this Application for Employment Authorization is true and correct, that the Applicant understands the penalties for false statements, and that the Applicant authorizes release of information contained in this application to verify eligibility and identity as permitted by law.

Warning: Knowingly filing false information or concealing a material fact may subject the Applicant to fines, imprisonment, deportation, removal proceedings, and ineligibility for immigration benefits. This form is subject to verification and audit by authorized officials.

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