Department of Homeland Security 1-765, Application for
US Citizenship and Immigration Services
Do not write in this block.
am applying for: Ixi Permission to acceptemployment.
Replacement(ofwst employment authorization document)
Renewal of my permission to acceptemployment (attach previou.~emplo,vmentauthorization document).
I Name (Fami.Jy Name in CAPS} (Firs!) (Middle) II Have you ever before applied for employment authorization from USCIS?
0 Yes (If yes, complete below) 0 No
2. Qther Names Used (Include Maiden Name) Which USCISOftice'! Oate(s)
Results (Granted or Denied -attach all documentation)
12 Date of Last Entry into the U.S. (mm/dd/yyyy)
4 CournryofCilizenship/Nalionalily 13 Place of Last Entry into the US.
14 Manner of Last Entry (Visitor, Student, etc.)
IS Currenllmmigration Status (Visitor, Student, etc
8 Mari~1 Statu"
0 Married O-~;~g--;:- 16 Go to Part 2 of the Instructiof!S, EligibilityCalegoriesln
the letter and number of the C;1tegory you selected from the instructions
the space below, place
0 Widowed 0 Divorced example, (;1)(8), (c)( 17)(iii);etc.).
9 Social Security Number (Include all numbers you have ever used) (if any)
Eligibility under 8 CI'R 274a 12
10 Aliell RegistratiQn Number (A-Number) or 1"94 Numb~r (i(any)
Your Certification: I certify, under penalty ofpeljury under the laws of the United States of America, that the foregoing is true and
correct. Furthermore, I authorize the release of any information that the US. Citizenship and Immigration Services needs to determine
eligibility for the benefit I am seeking. J have read the Instructions in Part 2 and havcidcntifit:d the appropriate eligibility category in
Signature of Person Preparing Form, If Other Than Above: I declare that this document was prepared by me at the
request of the applicant and is based on all information of which I have any knowledge.
PrintN~e Addres, Signature Date
HEARTLAND ~"""- '\'
0 Cover Letter
0 Application form 1-765
0 Question 15: Current Immigration Status = asylum applicant
0 Question 16: Eligibility Category for asylum applicants = c (8)
Eligibility Category for asylees = a (5)
0 If your client has some other status, check with MIHRC for the correct
0 2 passport style photos
0 Notice of Entry of Appearance as Attorney: form G-28 (blue paper)
Q Proof of Identity (good quality copy of passport, other photo ID, or birth
certificate and translation)
0 Copy of Referral Notice from the Asylum Office
0 Proof ot' a pending case
0 (Notice of next hearing or proof that case is pending an appeal)
0 Money order in the amount of $180 Renewing applicants only
0 Asylum applicants may request their first work permit without paying the fee.
0 Money order to: U.S Citizenship & Immigration Services
Things to RememberBefore You Apply:
.Client can apply after casehas been pending for ISOdays. (counted asdays elapsed
on case clock)
.Days only count if the client does nothing to delay the case. The clock stops if client
asks for a continuance.
.If your client is in court, call the 1.800.898.7180and choose option #2 to see how
many days have elapsed in the case.
Providing paths from harm to hope through hunUln servic(~s
208 S. LaSalle Street, Suite 1818, Chicago, Illinois 60604
phone: 312-660-1370 fax: 312-660-1505 website: www.mihrc.org