I-765 Form Sample

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I-765 Form: Application for Employment Authorization Confirmation Receipt LIN1280303199 USCIS Receipt Number: ASC Fingerprint Code: Date of Submission: 07/10/2012 First Name: Ma Cristina Middle Name: Viloria Family Name: delos Reyes Organization Name: Filing Fee: $ 380.00 Biometrics Fee: $ 0.00 Total Amount Paid: $ 380.00 Electronic Bank Account Debit Paid by: Thank you for e-Filing your application. Your receipt number is listed at the top of this page. We will mail you an official Receipt Notice (Form I-797C) with the same number, which you should receive within 10 days. These are the next steps in the application process: You MUST send us your supporting documentation before we will process your application. Use this…show more content…
Your receipt number is listed at the top of this page. We will mail you an official Receipt Notice (Form I-797C) with the same number, which you should receive within 10 days. These are the next steps in the application process: You MUST send us your supporting documentation before we will process your application. Use this confirmation receipt as a cover page and mail your documents to: USCIS Nebraska Service Center ATTN: E-Filed I-765 P.O. Box 87373 Lincoln, NE 68501-7373 • The form instructions, which can be found at http://www.uscis.gov/i-765, list the required documents. • Submit photos and copies of your identification if required. • Do not send your e-Filed form or unrelated documents, applications, or payments. • Keep a copy of this receipt and your application and supporting documents. We will mail you an appointment notice to have your photograph and/or fingerprints taken at a USCIS Application Support Center (ASC). • Follow the notice instructions, which will tell you the time, date and location of your appointment. • Do not go to the ASC prior to receiving your appointment notice. You must bring these items to your appointment, or it will be…show more content…
1. Name (Family Name in CAPS) (First) delos Reyes Which USCIS Office? LINCOLN, NE (Middle) Ma Cristina Viloria Results (Granted or Denied - attach all documentation) Granted 2. Other Names Used (Include Maiden Name) (Apt. Number) (Town or City) (State/Country) CA 12. Date of Last Entry into the U.S. 11/21/2008 (ZIP Code) 3. Address in the United States (Number and Street) 14311 Chase St Panorama City 13. Place of Last Entry into the U.S. DETROIT, MI 91402 4. Country of Citizenship/Nationality (mm/dd/yyyy) 14. Manner of Last Entry (Visitor, Student, etc.) SPECIALITY OCCUPATION PHILIPPINES 5. Place of Birth (Town or City) Date(s) 09/16/2010 (State/Province) 6. Date of Birth (mm/dd/yyyy) 10/29/1978 15. Current Immigration Status (Visitor, Student, etc.) (Country) Manila PHILIPPINES 7. Gender Male Female 8. Marital Status Single Married Widowed Divorced 9. Social Security Number (Include all numbers you have ever used) (if any) ( 09 ) )
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