Page 1 of 6Form I-910 05/29/18 To be completed by an attorney or accredited representative (if any). For USCIS Use OnlyApplication for Civil Surgeon Designation Department of Homeland Security U.S. Citizenship and Immigration ServicesSTART HERE - Type or print in black ink. USCIS Form I-910 Action Block Sent Received Initial Receipt Barcode Resubmitted Remarks Part 1. Information About You (The Applicant)1.a.Have you ever been designated as a civil surgeon?Period of Designation (mm/dd/yyyy)1.b.1.c.Civil Surgeon Identification Number (CSID) (if known) 1.d. FromTo Yes No2.a.Has USCIS ever revoked your designation? Yes NoDate of Revocation (mm/dd/yyyy)2.b.If you answered "Yes" to Item Number 2.a., provide the following information. 3.a.Have you ever voluntarily terminated your designation?If you answered "Yes" to Item Number 3.a., provide the following information. Yes NoNOTE: If you answered "Yes" to Item Number 2.a. or Item Number 3.a.Your Full Name Other Names Used4.a.Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name CSID Number Select this box if Form Middle Name5.a.Family Name (Last Name) 5.b. Given Name (First Name)List 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 9. Additional Information. Date of Voluntary Termination (mm/dd/yyyy)3.b. Other InformationDate of Birth (mm/dd/yyyy)6. 7.GenderMale Female American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 6Form I-910 05/29/18 Part 1. Information About You (The Applicant) (continued)9.A-Alien Registration Number (A-Number, if any) USCIS Online Account Number (if any)8. 2.c.2.d.City or TownState2.e.ZIP CodeStreet Number and Name2.a. 2.b.Apt. Flr. Ste. Telephone Number3. Part 2.240 Clinical Office LocationsYou must provide the following information. Failure to provide this information may result in the denial of your application. See the Additional Office Information section below for more information about what will be made publicly available.Name of Clinic/Practice 1. Name and Physical Address of the Clinic/Practice Provide the following information about the locations where you seek to perform immigration medical examinations. If you seek to perform immigration medical exams in more than one location, provide the details for each additional location in the space provided in Part 9. Additional Information.4.Fax Number Email Address (For Use By USCIS) 5.NOTE: USCIS will use the contact information listed above for all civil surgeon-related communication. 6.Email Address (For Use By The Public) 7.Website Address (URL) Fees for Medical Examination 8. Acceptable Means of Payment 9. Languages Spoken11. Part 3.240 Information About Your Status in the United States1.I am a U.S. citizen or national. (Attach proof that youare a U.S. citizen or national, such as a copy of a U.S.passport, birth certificate, or Certificate ofNaturalization.) You must be authorized to work in the United States to be eligible for civil surgeon designation. Select the box that accurately states how you are authorized to work in the United States. (Select only one box.) Other14. Accepted Medical Insurance Plans10. Office Hours12. Handicap Accessibility13. Additional Office InformationYour application will not be affected if you choose not to provide the following information. USCIS displays this information on our website for people who want to find a civil surgeon.UPDATE USCIS OF ANY CHANGES: Civil surgeons are responsible for notifying USCIS in writing of any updates to the contact information provided in this application within 15 days of the change. Visit the USCIS website at www.uscis.gov/I-910 for information on how to submit a change.I am a Lawful Permanent Resident. (Attach a copyof your valid Form I-551, Permanent Resident Card.If you are currently seeking to renew or replace yourForm I-551, attach evidence showing that you aredoing so.)2. (USPS ZIP Code Lookup) American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 6Form I-910 05/29/18 Dates of Attendance (mm/dd/yyyy)1.b. FromTo 1.c.Degree Part 4. Medical LicensesDate Issued (mm/dd/yyyy)1.c. Date Expires (mm/dd/yyyy)1.d. 1.a. State Medical License 1 U.S. Territory ORYou must be licensed to practice medicine in the state or U.S. territory in which you seek to perform immigration medical examinations to be eligible for civil surgeon designation. Attach a copy of each medical license listed below. If you need extra space to complete this section, use the space provided in Part 9. Additional Information. Medical License 2Date Issued (mm/dd/yyyy)2.c. Date Expires (mm/dd/yyyy)2.d. 2.b.Medical License Number 2.a. State ORU.S. Territory 4.I have an Employment Authorization Document(EAD) granted by USCIS that authorizes me towork in the United States. (Attach a copy of yourvalid, unexpired EAD as proof of your authorizationto work in the United States.) Part 3.240 Information About Your Status in the United States (continued)1.a. School Name School 1 Part 5.240 Medical DegreesYou must possess a medical degree as a Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) to be eligible for civil surgeon designation. Attach a copy of each medical degree listed below. If you need extra space to complete this section, use the space provided in Part 9. Additional Information.Passport Number3.e.Travel Document Number 3.d. Current Nonimmigrant Status3.h. Expiration Date for Passport or Travel Document (mm/dd/yyyy)3.g. 3.f. Country of Issuance for Passport or Travel DocumentDate of Last Arrival in the U.S. (mm/dd/yyyy)3.b. 3.c.Form I-94 Arrival-Departure Record Number (if any) I am currently present in the United States as a nonimmigrant. (Attach a copy of your Form I-94 Arrival-Departure Record, a copy of your passport or travel document, and any documents related to your nonimmigrant status, such as a copy of the petition, petition approval, and change or extension of status application. Also attach a copy of your valid, unexpired Employment Authorization Document as proof of your authorization to work in the United States, if required.)3.a. School 22.c.Degree 2.a. School Name Dates of Attendance (mm/dd/yyyy)2.b. FromTo 1.b.Medical License Number American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 6Form I-910 05/29/18 Part 7.240240Applicant's Statement, Contact Information, Declaration, Certification, and SignatureNOTE: If applicable, select the box for Item Number 1.NOTE: Read the Penalties section of the Form I-910 Instructions before completing this section. You must file Form I-910 while in the United States. Applicant's Statement Part 6.240 Professional Experience Employer 22.b.2.a. Employer's NameDates of Employment (mm/dd/yyyy) FromTo Employer 1Dates of Employment (mm/dd/yyyy)1.b.1.a. Employer's Name FromTo Employer's Daytime Telephone Number1.h.1.e.City or Town 1.f.State1.g.ZIP CodeStreet Number and Name1.c. 1.d.Apt.Flr.Ste. Employer's Daytime Telephone Number2.h.2.e.City or Town 2.f.State2.g.ZIP CodeStreet Number and Name2.c. 2.d.Apt.Flr.Ste. NOTE: In calculating whether you meet the requirement of four years of practice as a physician, DO NOT count your post graduate medical training in an internship or residency program. You can, however, count the time you practiced medicine on the basis of a post-residency fellowship.You must establish that you have practiced medicine as a physician (M.D. or D.O.) for at least four years to be eligible for designation.Submit evidence to establish your professional experience, such as evaluations, certificates of completion, business tax returns and business license (for self-employed physicians), or letters of employment verification. If you need extra space to complete this section, use the space provided in Part 9. Additional Information. 1.At my request, the preparer named in Part 8.,prepared this application for me based only upon information I provided or authorized., Applicant's Contact InformationApplicant's Daytime Telephone Number2. Applicant's Email Address (if any)4.Applicant's Mobile Telephone Number (if any)3. Applicant's Declaration and CertificationBy signing this appl