Form I-765 – Page 3: Applicant Information

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Part 3: Applicant Information

NOTE: Read the Penalties section of the Form I-765 Instructions before completing this section. You must file Form I-765 while in the United States.

Applicant's Statement

1.a. I can read and understand English, and I have read and understand every question and instruction on this application and my answer to every question.

1.b. The interpreter named in Part 4. read to me every question and instruction on this application and my answer to every question in

a language in which I am fluent and I understood everything.

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Please enter the interpreter's language.

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Please select either 1.a or 1.b.

2. At my request, the preparer named in Part 5.,

prepared this application for me based only upon information I provided or authorized.

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Please enter the preparer's name.

Applicant's Contact Information

3. Applicant's Daytime Telephone Number:

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Please enter a valid daytime telephone number.

4. Applicant's Mobile Telephone Number (if any):

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Please enter a valid mobile number.

5. Applicant's Email Address (if any):

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Please enter a valid email address.

6. Select this box if you are a Salvadoran or Guatemalan national eligible for benefits under the ABC settlement agreement.

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Applicant Sign Below

NOTE: Use your finger or mouse to draw your signature.

Don’t want to sign now? No worries — leave it blank and sign the PDF on paper or digitally later.

Next: Part 4: Interpreter's Info

Part 3: Applicant Information

Applicant's Statement

Applicant's Contact Information

Applicant Sign Below

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Part 3: Applicant Information

Applicant's Statement

Applicant's Contact Information

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