Page 1 of 7Form I-765 05/31/18 Authorization/Extension Valid Through Authorization/Extension Valid From For USCIS Use Only Application For Employment Authorization Department of Homeland Security U.S. Citizenship and Immigration ServicesUSCIS Form I-765 OMB No. 1615-0040 Expires 05/31/2020START HERE - Type or print in black ink. Part 1. Reason for Applying Your Full Legal Name1.a.Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Initial permission to accept employment.I am applying for (select only one box):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.a.1.b.Renewal of my permission to accept employment. (Attach a copy of your previous employment authorization document.)1.c. Action Block Fee Stamp Select this box if Form G-28 is attached.Attorney or Accredited Representative USCIS Online Account Number (if any) To be completed by an attorney or Board of Immigration Appeals (BIA)-accredited representative (if any). Part 2. Information About You Other Names UsedProvide 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. Middle Name4.c. Given Name (First Name) 4.b. Family Name (Last Name) 4.a.Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name Remarks A-Alien Registration Number American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 7Form I-765 05/31/18 Part 2. Information About You (continued) No YesIs your current mailing address the same as your physical address?6.NOTE: If you answered 223No224 to Item Number 6., provide your physical address below. U.S. Physical Address7.c.City or Town7.d.State7.e.ZIP Code7.b. Ste. Flr. Apt. 7.a. Street Number and Name Other Information USCIS Online Account Number (if any)9. A- 8.Alien Registration Number (A-Number) (if any)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.15. No YesNOTE: If you answered 223Yes224 to Item Numbers 14. - 15., provide the information requested in Item Numbers 16.a. - 17.b. Female MaleGender10. Widowed Divorced Single MarriedMarital Status11.12.Have you previously filed Form I-765? No YesFather's Name16.a.Family Name (Last Name) 16.b. Given Name (First Name) Mother's Name17.a.Family Name (Last Name) 17.b. Given Name (First Name) Provide your mother's birth name.Provide your father's birth name.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. Country18.b.Country Your Country or Countries of Citizenship or NationalityDo you want the SSA to issue you a Social Security card? (You must also answer 223Yes224 to Item Number 15., Consent for Disclosure, to receive a card.)14. No YesNOTE: If you answered 223No224 to Item Number 14., skip to Part 2., Item Number 18.a. If you answered 223Yes224 to Item Number 14., you must also answer 223Yes224 to Item Number 15.Provide your Social Security number (SSN) (if known).13.b. Your U.S. Mailing Address5.d.City or Town5.e.State5.f.ZIP Code5.c. Ste. Flr. Apt. 5.b. In Care Of Name (if any)5.a.Street Number and Name (USPS ZIP Code Lookup) Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? No Yes13.a.NOTE: If you answered 223No224 to Item Number 13.a., skip to Item Number 14. If you answered 223Yes224 to Item Number 13.a., provide the information requested in Item Number 13.b. American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 7Form I-765 05/31/18 Part 2. Information About You (continued)Travel Document Number (if any)21.c. 23.Place of Your Last Arrival Into the United States Date of Your Last Arrival Into the United States, On or About (mm/dd/yyyy)22.21.d.Country That Issued Your Passport or Travel Document21.e.Expiration Date for Passport or Travel Document (mm/dd/yyyy) Passport Number of Your Most Recently Issued Passport21.b. Immigration Status at Your Last Arrival (for example, B-2 visitor, F-1 student, or no status)24. Your Current Immigration Status or Category (for example, B-2 visitor, F-1 student, parolee, deferred action, or no status or category)25.Student and Exchange Visitor Information System (SEVIS) Number (if any)26.Employer's Name as Listed in E-Verify28.b. Employer's E-Verify Company Identification Number or a Valid E-Verify Client Company Identification Number28.c. 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.(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?30. YesNOTE: If you answered 223Yes224 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. No (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.a. Degree28.a. Information About Your Last Arrival in the United StatesForm I-94 Arrival-Departure Record Number (if any) 21.a. (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.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)).27. Information About Your Eligibility Category Date of Birth (mm/dd/yyyy)20. Country of Birth19.c.19.a. City/Town/Village of Birth State/Province of Birth 19.b.List the city/town/village, state/province, and country where you were born. Place of Birth ())()( NOTE: If you answered 223Yes224 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.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? Yes No31.b. N- American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 7Form I-765 05/31/18 The interpreter named in Part 4. read to me every question and instruction on this application and my answer to every question in 1.b.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.a. a language in which I am fluent, and I understood everything.,NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. Part 3. Applicant's Statement, Contact Information, Declaration, Certification, and Signature Applicant's StatementNOTE: 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. 2. At my request, the preparer named in Part 5.,prepared this a