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G-1145 Form PDF
Personalized Filling Instructions
Worksheet
Where to File
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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
For USCIS Use Only
Authorization/Extension
Valid From
Authorization/Extension
Valid Through
Fee Stamp
Action Block
Alien Registration Number
A-
Remarks
To be completed by an attorney or
Board of Immigration Appeals (BIA)-
accredited representative (if any).
Select this box if Form G-28 is attached.
Attorney or Accredited Representative USCIS Online Account Number (if any)
START HERE - Type or print in black ink.
Part 1. Reason for Applying
I am applying for (select only one box):
1.a.
Initial permission to accept employment.
1.b.
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.c.
Renewal of my permission to accept employment.
(Attach a copy of your previous employment
authorization document.)
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.
Family Name (Last Name)
2.b.
Given Name (First Name)
2.c.
Middle Name
3.a.
Family Name (Last Name)
3.b.
Given Name (First Name)
3.c.
Middle Name
4.a.
Family Name (Last Name)
4.b.
Given Name (First Name)
4.c.
Middle Name
Form I-765 Edition 04/01/24
Page 1 of 7
Part 2. Information About You (continued)
Your U.S. Mailing Address
5.a.
In Care Of Name (if any)
5.b.
Street Number and Name
5.c.
5.d.
City or Town
5.e.
State
5.f.
ZIP Code
(USPS ZIP Code Lookup)
6.
Is your current mailing address the same as your physical address?
NOTE: If you answered “No” to Item Number 6., provide your physical address below.
U.S. Physical Address
7.a.
Street Number and Name
7.b.
7.c.
City or Town
7.e.
State
7.f.
ZIP Code
Other Information
8.
Alien Registration Number (A-Number) (if any)
A-
9.
USCIS Online Account Number (if any)
10.
Gender
11.
Marital Status
12.
Have you previously filed Form I-765?
13.a.
Has the Social Security Administration (SSA) ever
officially issued a Social Security card to you?
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.)
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
Social Security card.
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
Form I-765 Edition 04/01/24
Page 2 of 7
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., 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.
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
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.
Form I-765 Edition 04/01/24
Page 3 of 7
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.
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
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)
Form I-765 Edition 04/01/24
Page 4 of 7
Part 4. Interpreter's Contact Information,
Certification, and Signature
Interpreter's Mailing Address
3.a.
Street Number and Name
3.b.
3.c.
City or Town
3.d.
State
3.e.
ZIP Code
3.f.
Province
3.g.
Postal Code
3.h.
Country
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)
Interpreter's Certification
I certify, under penalty of perjury, that:
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.
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
3.a.
Street Number and Name
3.b.
3.c.
City or Town
3.d.
State
3.e.
ZIP Code
3.f.
Province
3.g.
Postal Code
3.h.
Country
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)
Form I-765 Edition 04/01/24
Page 5 of 7
Part 5. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other Than the Applicant (continued)
Preparer's Statement
7.a.
I am not an attorney or accredited representative
but have prepared this application on behalf of
the applicant and with the applicant's consent.
7.b.
I am an attorney or accredited representative and my representation of the applicant in
this case
extends
does not extend beyond the preparation of this application.
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 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)
Form I-765 Edition 04/01/24
Page 6 of 7
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.
1.a.
Family Name (Last Name)
1.b.
Given Name (First Name)
1.c.
Middle Name
2.
A-Number (if any)
A-
3.a.
Page Number
3.b.
Part Number
3.c.
Item Number
3.d.
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.
Form I-765 Edition 04/01/24
Page 7 of 7
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