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Security Form I 765


									        How to complete Form I-765 (17-Month OPT STEM extension)
    •    Do not write in the block at the top of Form I-765.

    •    Below the block at the top of the form, where it says “I am applying for” mark:
          □ “Renewal of my permission to accept employment.” Remember to include a copy of your current
         EAD card.

1. LAST NAME, first name, and middle name.            Your name should be spelled exactly as it appears on your
   passport and OPT I-20.

2. Reserve this line in case you need extra room to list your address.

3. Be sure to list a valid, physical U.S. mailing address. THIS IS VERY IMPORTANT! Listing an invalid address
   can cause serious delays in receiving your EAD. You may NOT use a P.O. Box. Please note that you must mail
   your application to the USCIS Service Center serving the state of the address listed in this section.

4. Country of Citizenship/Nationality (Should match the information on your passport.)

5. Place of birth (Should match the information on your passport.)

6. List the mo./day/yr. you were born. (Should match the information on your passport.)

7. Gender

8. Current marital status

9. List your U.S. Social Security number. If you do not have a U.S. Social Security number, write “Do not have
   SSN” in the blank.

10. List the 11-digit number on your most recent I-94 card.

11. Mark “yes” since you have previously applied for an EAD card from USCIS (your current OPT).

    List the USCIS office where you applied for the first 12-month post-completion OPT and the date on which you
    applied (receipt date on I-797C Notice of Action). If you applied for other work authorizations from USCIS in
    addition to the most recent OPT, please list them as well.
    Provide a copy of your EAD card and I-20 with the OPT recommendation from your current OPT as well as any
    previously granted periods of employment by USCIS.

12. Date of last entry to the U.S. should be on your most recent I-94 card.

13. List the city or port of entry code. Port of Entry code should be listed on your most recent I-94 card.

14. Manner of last entry to the U.S.: If you entered the US last as an F-1 student, list “F-1 student.” If you last
    entered the U.S. as an F-2 spouse or B-2 tourist, etc., enter that information instead.

15. List “F-1 student.”

16. Fill in (c) (3) (C)

17. List your degree (level and major) as it appears in SEVIS.
    List your employer’s name as it is listed in E-Verify.
    List your employer’s E-verify number.

Carefully read the statement and carefully check to make sure you have properly and completely completed the
form. Sign and date the form.

Only if you are unable to complete the form yourself: you will have to someone complete the form on your behalf
are read and sign the bottom of the form in the place marked “Signature of Person Preparing Form, If Other Than

                                                                                                 Rvsd. 10/26/07,nh
                                                                                                                                OMB No. 1615-0040; Expires 08/31/08

Department of Homeland Security
                                                                                                                              I-765, Application For
U.S. Citizenship and Immigration Services                                                                                 Employment Authorization
Do not write in this block.
 Remarks                                                Action Block                                                     Fee Stamp


 Applicant is filing under §274a.12
      Application Approved. Employment Authorized / Extended (Circle One)                            until                                                        (Date).
      Subject to the following conditions:
      Application Denied.
          Failed to establish eligibility under 8 CFR 274a.12 (a) or (c).
          Failed to establish economic necessity as required in 8 CFR 274a.12(c)(14), (18) and 8 CFR 214.2(f)
I am applying for:             Permission to accept employment.
                               Replacement (of lost employment authorization document)
                               Renewal of my permission to accept employment (attach previous employment authorization document).
1. Name (Family Name in CAPS) (First)                              (Middle)                Which USCIS Office?                                        Date(s)

2. Other Names Used (Include Maiden Name)                                                   Results (Granted or Denied - attach all documentation)

3. Address in the United States (Number and Street)                (Apt. Number)       12. Date of Last Entry into the U.S.     (mm/dd/yyyy)

  (Town or City)                      (State/Country)               (ZIP Code)          13. Place of Last Entry into the U.S.

4. Country of Citizenship/Nationality                                                   14. Manner of Last Entry (Visitor, Student, etc.)

5. Place of Birth (Town or City)      (State/Province)             (Country)            15. Current Immigration Status (Visitor, Student, etc.)

6. Date of Birth (mm/dd/yyyy)                   7. Gender                               16. Go to Part 2 of the Instructions, Eligibility Categories. In the space below,
                                                                                            place the letter and number of the category you selected from the instructions
                                                          Male         Female               (For example, (a)(8), (c)(17)(iii), etc.).
8. Marital Status         Married                    Single
                          Widowed                    Divorced
                                                                                        Eligibility under 8 CFR 274a.12 (             )     (           )     (          )
9. Social Security Number (Include all numbers you have ever used) (if any)             17. If you entered the Eligibility Category, (c)(3)(C), in item 16 above, list your
                                                                                            degree, your employer's name as listed in E-Verfy, and your employer's E-
                                                                                            Verify Company Identification Number or a valid E-Verify
10. Alien Registration Number (A-Number) or I-94 Number (if any)                            Client Company Identification Number in the space below.
11. Have you ever before applied for employment authorization from USCIS?               Employer's Name as listed in E-Verify:
        Yes (If yes, complete below)                               No                   Employer's E-Verify Company Identification Number or a valid E-Verify
                                                                                        Client Company Identification Number

Your Certification: I certify, under penalty of perjury 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 U.S. Citizenship and Immigration Services needs to determine
eligibility for the benefit I am seeking. I have read the Instructions in Part 2 and have identified the appropriate eligibility category in
Block 16.
Signature                                                                                      Telephone Number                                        Date

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.
      Print Name                                         Address                                             Signature                                 Date

                                                          Initial Receipt        Resubmitted             Relocated                                Completed
                                                                                                    Rec'd            Sent        Approved          Denied         Returned

                                                                                                                                            Form I-765 (Rev. 05/27/08) N

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