| 2. Other Names Used (Include Maiden Name) |
|
| 3. Address in the United States (Number and Street) |
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| (Apt.No.) |
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| (Town or City) |
|
| (State/Country) |
|
| (Zip/Postal Code) |
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| 4. Country of Citizenship/Nationality |
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| 5. Place of Birth (Town or City) |
|
| (State/Province) |
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| (Country) |
|
| 6. Date of Birth |
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| 7. Sex |
Male
Female
|
| 8. Marital Status |
Married
Single
Widowed
Divorced
|
| 9. Social Security Number (Include all Numbers you have ever used) (if any) |
|
| 10. Alien Registration Number (A-Number) or I-94 Number (if any) |
|
| 11. Have you ever before applied for employment authorization from USCIS? |
Yes (If yes, complete below)
No
|
| Which USCIS Office? |
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| Date(s) |
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| Results (Granted or Denied - attach all documentation) |
|
| 12. Date of Last Entry into the U.S. (Month/Day/Year) |
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| 13. Place of Last Entry into the U.S. |
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| 14. Manner of Last Entry (Visitor, Student, etc.) |
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| 15. Current Immigration Status (Visitor, Student, etc.) |
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16. Go to Part 2 of the Instructions, Eligibility Categories. In the space below, place the letter and number of the category you selected from the instructions (For example, (a)(8), (c)(17)(iii), etc.).
Eligibility under 8 CFR 274a.12 |
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