Application for Authorization to Issue Certification for Health Care Workers Department of Homeland Security U.S. Citizenship and Immigration Services Returned Reloc Sent Receipt Approved for all requested occupations. Partial approval (USCIS must list approved occupations.) USCIS Form I-905 Action Block For Resubmitted USCIS Use Only Reloc Rec'd VOLAG# To Be Completed by Attorney or Representative, if any Select the box if Form G-28 is attached to represent the applicant ATTY State License Number START HERE - Please type or print in black ink. Part 1. Information About the Applicant Filing This Form 1. Name of Company or Organization Description of your organization. Address 2.a. Street Number and Name 2.b. Apt. Ste. Flr. Occupations for which you are seeking authorization. 2.c. City or Town 2.d. State 3. 2.e. ZIP Code IRS Tax Number Describe the process you will use to issue certificates. Point of Contact 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name 5. Title 6. Date the organization was created. (mm/dd/yyyy) Form I-905 02/11/14 Y Page of American LegalNet, Inc. www.FormsWorkFlow.com Part 1. Information About the Applicant Filing This Form (continued) Explain your organization's expertise, knowledge, and experience in the health care occupations for which you are seeking authorization. I certify, under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct. Copies of documents submitted are exact photocopies of unaltered original documents, and I understand that I may be required to submit original documents to U.S. Citizenship and Immigration Services (USCIS) at a later date. Furthermore, I authorize the release of any information from my records that USCIS may need to determine my eligibility for the benefit that I seek. I furthermore authorize release of information contained in this form, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration of U.S. immigration laws. Explain how your organization meets the standards described in the instructions sheet. 3.a. Applicant's Signature 3.b. Date of Signature (mm/dd/yyyy) Applicant's Contact Information Describe the procedure you will establish for U.S. Citizenship and Immigration Services to use to verify the validity of your certificates. 4. Applicant's Daytime Telephone Number 5. Applicant's E-mail Address Part 3. Contact Information, Certification, and Signature of the Interpreter Part 2. Statement, Certification, Signature, and Contact Information of the Applicant Filing This Form 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 have read and understand each and every question and instruction on this form, as well as my answer to each question. The interpreter named in Part 3. has read to me each and every question and instruction on this form, as well as my answer to each question, in , a language in which I am fluent. I understand each and every question and instruction on this form as translated to me by my interpreter, and have provided true and correct responses in the language indicated above. 2. I have requested the services of and consented to 3.d. State , who is is not an attorney or accredited representative, preparing this form for me. Form I-905 02/11/14 Y Page of American LegalNet, Inc. www.FormsWorkFlow.com Interpreter's Full Name Provide the following information concerning the interpreter: 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) 1.b. Interpreter's Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.e. ZIP Code Part 3. Contact Information, Certification, and Signature of the Interpreter (continued) Interpreter's Contact Information 4. Interpreter's Daytime Telephone Number Preparer's Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.e. ZIP Code 5. Interpreter's E-mail Address Preparer's Contact Information Interpreter Certification I certify that: I am fluent in English and which is the same language provided in Part 2., Item Number 1.b.; I have read to this applicant each and every question and instruction on this form, as well as the answer to each question, in the language provided in Part 2., Item Number 1.b.; and The applicant has informed me that he or she understands each and every instruction and question on the form, as well as the answer to each question. 6.a. Interpreter's Signature , 5. Preparer's Fax Number 4. Preparer's Daytime Telephone Number 6. Preparer's E-mail Address 7.a. I am not an attorney or accredited representative but have prepared this form on behalf of the applicant and with the applicant's consent. I am an attorney or accredited representative and my representation of the applicant in this case (choose one) extends does not extend beyond the preparation of this form. 7.b. 6.b. Date of Signature (mm/dd/yyyy) Preparer's Declaration Part 4. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other than the Applicant Preparer's Full Name Provide the following information concerning the preparer: 1.a. Preparer's Family Name (Last Name) 8.a. Preparer's Signature 1.b. Preparer's Given Name (First Name) 8.b. Date of Signature (mm/dd/yyyy) 2. Preparer's Business or Organization Name NOTE: If you do not completely fill out this form or fail to submit required documents listed in the instructions, this application may be denied. By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this form on behalf of, at the request of, and with the express consent of the applicant. I completed the form based only on responses the applicant provided to me. After completing the form, I reviewed it and all of the applicant's responses with the applicant, who agreed with each and every answer provided for each question on the form and, when required, supplied additional information to respond to a question on the form. Form I-905 02/11/14 Y Page of American LegalNet, Inc. www.FormsWorkFlow.com