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I - 765: Application for Employment Authorization G - 28 Addendum

In order to electronically process your application, you must provide information for the items marked * below. File Number: I hereby enter my appearance as attorney for (or representative of) and at the request of the following named person: John or Jane     DOE  *  Petitioner   Applicant   Beneficiary   * Select applicable item(s): 1. Attorney in Good Standing:   I am an attorney and a member in good standing of the bar of the Supreme Court of the United States or of the highest court of the following State, territory, insular possesion, or District of Columbia, and am not under a court order suspending, enjoining, restraining or disbarring or otherwise restricting me in practicing law. State, Territory, or Insular Possession: Select a State ALABAMA ALASKA AMERICAN SAMOA APO ZIPs beginning with 340 APO ZIPs between 090 and 098 APO ZIPs between 962 and 966 ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FEDERATED STATES OF MICRONESIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARSHALL ISLAND MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA NORTHERN MARIANA ISLANDS OHIO OKLAHOMA OREGON PALAU PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING Name of Court: 2. Accredited Representative:   I am an accredited representative of the following named religious, charitable, social service, or similar organization established in the United States and which is so recognized by the Board. Name of Organization: 3. Associated Attorney:   I am associated with the following attorney of record previously filed a notice of appearance in this case and my appearance is at his request. (If you check this item, also check item 1 or 2, whichever is appropriate.) Name of Attorney: 4. Others (Give full explanation): Please certify your appearance as attorney for (or representative of) your client by selecting the box below. *   Attorney Certification Consent Disclosure PURSUANT TO THE PRIVACY ACT OF 1974, I HEREBY CONSENT TO THE DISCLOSURE TO THE FOLLOWING NAMED ATTORNEY OR REPRESENTATIVE OF ANY RECORD PERTAINING TO ME WHICH APPEARS IN ANY BUREAU OF CITIZENSHIP AND IMMIGRATION SERVICES SYSTEM OF RECORDS: Attorney/Representative Information First Name: Middle Name: Last Name:  *  Address:  *  City:  *  State:  *  Select a State ALABAMA ALASKA AMERICAN SAMOA APO ZIPs beginning with 340 APO ZIPs between 090 and 098 APO ZIPs between 962 and 966 ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FEDERATED STATES OF MICRONESIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARSHALL ISLAND MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA NORTHERN MARIANA ISLANDS OHIO OKLAHOMA OREGON PALAU PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING Zip Code:  *  Telephone Number:   -    -  *   Certification of the Applicant THE ABOVE CONSENT TO DISCLOSURE IS IN CONNECTION WITH THE FOLLOWING MATTER: In order to electronically process your application, you must provide information for the items marked *. Please read our Secure Site Statement. For assistance or questions regarding this form, please call our National Customer Service Center at 1-800-375-5283 [TTY 1-800-767-1833].