OMB No. 1615-0040; Expires 08/31/08
Applicant is filing under §274a.12
Application Approved. Employment Authorized / Extended (Circle One)
Subject to the following conditions:
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)
Permission to accept employment.
I am applying for:
2. Other Names Used (Include Maiden Name)
3. Address in the United States (Number and Street)
12. Date of Last Entry into the U.S. (mm/dd/yyyy)
(Town or City)
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)
15. Current Immigration Status (Visitor, Student, etc.)
6. Date of Birth (mm/dd/yyyy)
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
(For example, (a)(8), (c)(17)(iii), etc.).
9. Social Security Number (Include all numbers you have ever used) (if any)
Eligibility under 8 CFR 274a.12
10. Alien Registration Number (A-Number) or I-94 Number (if any)
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
Signature of person preparing form, if other than above: I declare that this document was prepared by me at the