OMB No. 1615-0018; Exp. 09/30/2012 Form I-212, Application for Permission to Reapply for Admission Into the United States After Deportation or Removal Department of Homeland Security U.S. Citizenship and Immigration Services For Government Use Only Fee Stamp RECEIVED RET'D-TRANS.-OUT TRANS. IN COMPLETED Date This space for use by DHS officer Date of Action File A Decision DD or OIC Office Applicants Start Here (To be filed in duplicate) PART I. INFORMATION ABOUT YOU First Name Last Name Middle Name Alien registration number (A#) if known, or Alien File(s) or receipt number(s) and any immigration file(s) or case number(s) listed on correspondence from U.S. immigration authorities that relate to you Other names used or known by Place of Birth (City or Town) Name used when last deported or removed from the United States State Country of Citizenship or Nationality Province Date of Birth Country PART II. REASON FOR FILING THIS FORM I am inadmissible to the United States for the following reason(s) and no others: I have been removed as an arriving alien in expedited removal proceedings under INA section 235(b)(1), or I was removed at the end of proceedings under INA section 240 as an arriving alien (INA section 212(a)(9)(A)(i)). I have only been removed once, and my last removal was less than 5 years ago. I have been removed at least twice or more, and my last removal was less than 20 years ago. I have been convicted of an aggravated felony (in the United States or elsewhere, before or after my removal from the United States). I have been removed as a deportable alien under INA section 240 or any other provision of the law, or I departed the United States while an order or removal was outstanding (INA section 212(a)(9)(A)(ii)). I have only been removed once and less than 10 years ago. I have been removed at least twice or more, and my last removal was less than 20 years ago. I have been convicted of an aggravated felony (in the United States or elsewhere, before or after my removal from the United States). Form I-212 (09/11/11) Y American LegalNet, Inc. www.FormsWorkFlow.com I entered or attempted to enter the United States without being admitted or paroled after having been removed (INA section 212(a)(9)(C)(i)(I)). Specify date of last departure from the United States after having become inadmissible: (Attach evidence that demonstrates the date of your last departure from the United States and that you have remained outside the United States for 10 years.) I entered or attempted to enter the United States without being admitted or paroled after having been unlawfully present in the United States for a period of more than 1 year, in the aggregate (INA section 212(a)(9)(C)(i)(I)). Specify date of last departure from the United States after having become inadmissible: (Attach evidence that demonstrates the date of your last departure from the United States and that you have remained outside the United States for 10 years.) PART III. INFORMATION ABOUT YOUR REMOVAL/DEPORTATION AND DEPARTURE Date of deportation or removal from the United States If you have not been in removal proceedings, date of last departure from the United States (Attach evidence) Place of residence at time of deportation or removal from United States (city and state) Place deportation or removal hearing held or application for removal made (city and state) Detention facility or jail where detained (city and state) (If not detained, write "None.") Length of residence in the United States (years) Country to which deported or removed Port/location of departure from the United States PART IV. REASON(S) FOR YOUR REQUEST FOR PERMISSION TO REAPPLY Status desired if permitted to reenter the United States: Permanent Resident Visitor Student Other (specify) Reason(s) for desiring to reenter the United States: Form I-212 (09/11/11) Y Page 2 American LegalNet, Inc. www.FormsWorkFlow.com REASON(S) FOR YOUR REQUEST FOR PERMISSION TO REAPPLY (Cont'd) Location of U.S. Embassy/consulate where application for visa is/or will be made (city and country) Name and relationship of U.S. citizen or lawful permanent resident alien spouse, parent or children, if any PART V. APPLICANT'S SIGNATURE AND CERTIFICATION I certify under penalty of perjury under the laws of the United States that this application and the evidence submitted with it are all true and correct to the best of my knowledge and abilities. I authorize the release of any information from my records that U.S. Citizenship and Immigration Services (USCIS) or any other agency adjudicating this application needs to determine my eligibility for the benefits sought with this application. Signature of Applicant or Legal Guardian Date of Signature Applicant's Street Address (You must provide a physical address.) P.O. Box (If applicable) State Applicant's Mobile Telephone Number City Province State Zip Code Province Applicant's Telephone Number Country Applicant's E-mail Address (if any) PART VI. PREPARER'S SIGNATURE AND CERTIFICATION (If other than applicant) I declare that this document was prepared by me at the request of the applicant or legal guardian of the applicant, and that is based on all information of which I have knowledge and/or was provided to me by the above named person in response to the exact questions contained on this form. I have not knowingly withheld any information. Signature of Preparer Date of Signature Preparer's Street Address State City P.O. Box (If applicable) State Preparer's Mobile Telephone Number Province Country Zip Code Province Preparer's Telephone Number Preparer's E-mail Address (if any) Form I-212 (09/11/11) Y Page 3 American LegalNet, Inc. www.FormsWorkFlow.com