Part 3. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature
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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.
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NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
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Applicant's Contact Information |
3.
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Applicant's Daytime Telephone Number
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4.
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Applicant's Mobile Telephone Number (if any)
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5.
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Applicant's Email Address (if any)
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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.
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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.
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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:
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1)
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I reviewed and understood all of the information
contained in, and submitted with, my application; and
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2)
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All of this information was complete, true, and correct
at the time of filing.
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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.
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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.
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Part 4. Interpreter's Contact Information,
Certification, and Signature
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Provide the following information about the interpreter.
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1.a.
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Interpreter's Family Name (Last Name)
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1.b.
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Interpreter's Given Name (First Name)
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2.
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Interpreter's Business or Organization Name (if any)
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