Information about the applicant filing this form.
START HERE - Please type or print in black ink.
IRS Tax #
Phone # of Point of Contact
Title of Point of Contact
Date organization was created.
Description of your organization.
Fill in box if G-28 is attached to
represent the petitioner
ATTY State License #
Describe the process you will use to issue certificates (If more space is required,
use a separate sheet(s) of paper).
Occupations for which you are seeking authorization.
Explain your organization's expertise, knowledge and experience in the health
care occupations for which you are seeking authorization.
Approved for all requested
Partial approval (USCIS must list
To Be Completed by
Attorney or Representative, if any
For USCIS Use Only
Company or Organization
Street Number and Name
I-905, Application for Authorization to
Issue Certification for Health Care Workers
OMB No. 1615-0086; Expires 06/30/09
Department of Homeland Security
U.S. Citizenship and Immigration Services
Name of Point of Contact
Form I-905 (Rev. 07/30/07) Y
Part 3. Signature of person preparing form, if other than above. (Sign below.)
I declare that I prepared this application at the request of the above person and it is based on all information of which I have
Part 2. Signature. Read the information on penalties in the instructions before completing this section.
Signature and Title
I certify, under penalty of perjury under the laws of the United States of America, that this application and the evidence submitted with it are all
true and correct. If filing this on behalf of an organization, I certify that I am empowered to do so by that organization. I authorize the release of
any information from my records or from the applicant's organization's records that U.S. Citizenship and Immigration Services needs to determine