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I - 765: Application for Employment Authorization

Please review the information below. If you wish to edit the information, use the links above. If the information is correct, you must certify it.   Family Name: DOE   First Name: John or Jane   Middle Name:   Other Names Used:   Number and Street: 123 Main Street   Apt. Number:   Town or City: Anytown   State: TN   Zip Code: 38119   Country of Citizenship/Nationality: UNITED KINGDOM   Town or City of Birth: Anytown   State/Province of Birth:   Country of Birth: INDIA   Date of Birth: 01  / 01    /  1901      Sex: Male or Female   Marital Status: Single or Married   Social Security #: 000  -  00  -  0000            A#: A00000000   OR     I-94#:     Have you ever before applied for employment authorization from BCIS? Yes   If yes, which BCIS office? MEM   Date for application: 01  /  01  /  1901      Results: Granted   BCIS office:   Date for application:   Results:   BCIS office:   Date for application:   Results:     Date of Last Entry into the U.S.: 01  /  01  /  1901      Place of Last Entry into the U.S.: TN   Manner of Last Entry into the U.S.: (Visitor, Student, etc.) DA   Current Immigration Status: (Visitor, Student, etc.) 1B1   Please select your eligibility status: (c)(9)FILED I-485   For (c)(9) eligibility status only Please select the location where your I-485 is pending: ANYTOWN   Please provide information concerning your eligibility status:   Applicant filed marriage-based adjustment in Memphis; file transferred to Tampa when she moved.     Applying For: I-765   Filing Fee: $120.00   Total Amount Due: $120.00   Account Owner First Name: John or Jane   Account Owner Middle Name:   Account Owner Last Name: Doe   Bank Statement Address 1: 123 Main Street   Bank Statement Address 2:     City: Anytown   State: TN   Zip Code: 38119   Account Owner Phone Number: 901  -  555  -  0000      Account Type: Checking     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 which the Bureau of Citizenship and Immigration Services needs to determine eligibility for the benefit I am seeking. I have read Instructions and have identified the appropriate eligibility category.   Certification:  *      Date: 05/29/2003   Daytime Phone Number:  -   -      Certification of person preparing the form, if other than above I declare that this application was prepared by me at the request of the above person and it is based on all information of which I have knowledge.   Certification:     Type Your Name:   Date: 05/29/2003   Daytime Phone Number:  -   -    Address:      I intend to mail supporting documentation for this application.   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].