Application For Employment Authorization USCIS

Form I-765
Department of Homeland Security OMB No. 1615-0040
U.S. Citizenship and Immigration Services Expires 01/31/2023

Authorization/Extension Fee Stamp Action Block

Valid From

Authorization/Extension
For Valid Through
USCIS
Use
Only
Alien Registration Number A-

Remarks

To be completed by an attorney or Select this box if Form G-28 Attorney or Accredited Representative
Board of Immigration Appeals (BIA)- is attached. USCIS Online Account Number (if any)
accredited representative (if any).

► START HERE - Type or print in black ink.

Part 1. Reason for Applying Other Names Used

I am applying for (select only one box): Provide all other names you have ever used, including aliases,
maiden name, and nicknames. If you need extra space to
1.a. Initial permission to accept employment.
complete this section, use the space provided in Part 6.
1.b. Replacement of lost, stolen, or damaged employment Additional Information.
authorization document, or correction of my
2.a. Family Name
employment authorization document NOT DUE to (Last Name)
U.S. Citizenship and Immigration Services (USCIS) 2.b. Given Name
error. (First Name)
NOTE: Replacement (correction) of an employment 2.c. Middle Name
authorization document due to USCIS error does not
require a new Form I-765 and filing fee. Refer to
3.a. Family Name
Replacement for Card Error in the What is the (Last Name)
Filing Fee section of the Form I-765 Instructions for 3.b. Given Name
further details. (First Name)
1.c. Renewal of my permission to accept employment. 3.c. Middle Name
(Attach a copy of your previous employment
authorization document.)
4.a. Family Name
(Last Name)
4.b. Given Name
Part 2. Information About You (First Name)
4.c. Middle Name
Your Full Legal Name
1.a. Family Name Vallecillo Burgalin
(Last Name)
1.b. Given Name Luis
(First Name)
1.c. Middle Name Alexander

Form I-765 Edition 07/26/22 Page 1 of 7

Part 2. Information About You (continued) 13.b. Provide your Social Security number (SSN) (if known).
►
Your U.S. Mailing Address 14. Do you want the SSA to issue you a Social Security card?
(You must also answer “Yes” to Item Number 15.,
5.a. In Care Of Name (if any) Consent for Disclosure, to receive a card.)
Yes No
5.b. Street Number 5546 Filmore Avenue
and Name NOTE: If you answered “No” to Item Number 14., skip
to Part 2., Item Number 18.a. If you answered “Yes” to
5.c. Apt. Ste. Flr. Item Number 14., you must also answer “Yes” to Item
Number 15.
5.d. City or Town Alexandria
15. Consent for Disclosure: I authorize disclosure of
5.e. State VA 5.f. ZIP Code 22311 information from this application to the SSA as required
for the purpose of assigning me an SSN and issuing me a
(USPS ZIP Code Lookup)
Social Security card. Yes No
6. Is your current mailing address the same as your physical
address? Yes No NOTE: If you answered “Yes” to Item Numbers
14. - 15., provide the information requested in Item
NOTE: If you answered “No” to Item Number 6., Numbers 16.a. - 17.b.
provide your physical address below.
Father's Name

U.S. Physical Address Provide your father's birth name.

16.a. Family Name
7.a. Street Number 5546 Filmore Avenue (Last Name)
and Name
16.b. Given Name
7.b. Apt. Ste. Flr. (First Name)

7.c. City or Town Alexandria Mother's Name

Provide your mother's birth name.
7.d. State VA 7.e. ZIP Code 22311
17.a. Family Name
(Last Name)
Other Information 17.b. Given Name
(First Name)
8. Alien Registration Number (A-Number) (if any)
► A-
Your Country or Countries of Citizenship or
9. USCIS Online Account Number (if any) Nationality
► List all countries where you are currently a citizen or national.
If you need extra space to complete this item, use the space
10. Gender Male Female provided in Part 6. Additional Information.
11. Marital Status 18.a. Country
Single Married Divorced Widowed

12. Have you previously filed Form I-765? 18.b. Country

Yes No

13.a. Has the Social Security Administration (SSA) ever

officially issued a Social Security card to you?
Yes No

NOTE: If you answered “No” to Item Number 13.a.,

skip to Item Number 14. If you answered “Yes” to Item
Number 13.a., provide the information requested in Item
Number 13.b.

Form I-765 Edition 07/26/22 Page 2 of 7

Part 2. Information About You (continued) Information About Your Eligibility Category
27. Eligibility Category. Refer to the Who May File Form
Place of Birth I-765 section of the Form I-765 Instructions to determine
the appropriate eligibility category for this application.
List the city/town/village, state/province, and country where
Enter the appropriate letter and number for your eligibility
you were born.
category below (for example, (a)(8), (c)(17)(iii)).
19.a. City/Town/Village of Birth ( )( )( )

28. (c)(3)(C) STEM OPT Eligibility Category. If you

19.b. State/Province of Birth entered the eligibility category (c)(3)(C) in Item Number
27., provide the information requested in Item Numbers
28.a - 28.c.
19.c. Country of Birth
28.a. Degree

28.b. Employer's Name as Listed in E-Verify

20. Date of Birth (mm/dd/yyyy)

28.c. Employer's E-Verify Company Identification Number or a

Information About Your Last Arrival in the Valid E-Verify Client Company Identification Number
United States
21.a. Form I-94 Arrival-Departure Record Number (if any)
29. (c)(26) Eligibility Category. If you entered the eligibility
► category (c)(26) in Item Number 27., provide the receipt
number of your H-1B spouse's most recent Form I-797
21.b. Passport Number of Your Most Recently Issued Passport
Notice for Form I-129, Petition for a Nonimmigrant
Worker.
21.c. Travel Document Number (if any) ►

30. (c)(8) Eligibility Category. If you entered the eligibility

category (c)(8) in Item Number 27., have you EVER
21.d. Country That Issued Your Passport or Travel Document
been arrested for and/or convicted of any crime?
Yes No
21.e. Expiration Date for Passport or Travel Document
NOTE: If you answered “Yes” to Item Number 30.,
(mm/dd/yyyy) refer to Special Filing Instructions for Those With
Pending Asylum Applications (c)(8) in the Required
22. Date of Your Last Arrival Into the United States, On or
Documentation section of the Form I-765 Instructions
About (mm/dd/yyyy)
for information about providing court dispositions.
23. Place of Your Last Arrival Into the United States 31.a. (c)(35) and (c)(36) Eligibility Category. If you entered
the eligibility category (c)(35) in Item Number 27., please
provide the receipt number of your Form I-797 Notice for
24. Immigration Status at Your Last Arrival (for example, Form I-140, Immigrant Petition for Alien Worker. If you
B-2 visitor, F-1 student, or no status) entered the eligibility category (c)(36) in Item Number
27., please provide the receipt number of your spouse's or
parent's Form I-797 Notice for Form I-140.
25. Your Current Immigration Status or Category (for example, ►
B-2 visitor, F-1 student, parolee, deferred action, or no
status or category) 31.b. If you entered the eligibility category (c)(35) or (c)(36) in
Item Number 27., have you EVER been arrested for
and/or convicted of any crime? Yes No
26. Student and Exchange Visitor Information System
(SEVIS) Number (if any) NOTE: If you answered “Yes” to Item Number 31.b.,
► N- refer to Employment-Based Nonimmigrant Categories,
Items 8. - 9., in the Who May File Form I-765 section
of the Form I-765 Instructions for information about
providing court dispositions.

Form I-765 Edition 07/26/22 Page 3 of 7

Part 3. Applicant's Statement, Contact Applicant's Declaration and Certification
Information, Declaration, Certification, and Copies of any documents I have submitted are exact photocopies
Signature of unaltered, original documents, and I understand that USCIS
may require that I submit original documents to USCIS at a later
NOTE: Read the Penalties section of the Form I-765 date. Furthermore, I authorize the release of any information
Instructions before completing this section. You must file from any and all of my records that USCIS may need to
Form I-765 while in the United States. determine my eligibility for the immigration benefit that I seek.

Applicant's Statement I furthermore authorize release of information contained in this

application, in supporting documents, and in my USCIS
NOTE: Select the box for either Item Number 1.a. or 1.b. If records, to other entities and persons where necessary for the
applicable, select the box for Item Number 2. administration and enforcement of U.S. immigration law.
1.a. I can read and understand English, and I have read I understand that USCIS may require me to appear for an
and understand every question and instruction on this appointment to take my biometrics (fingerprints, photograph,
application and my answer to every question. and/or signature) and, at that time, if I am required to provide
biometrics, I will be required to sign an oath reaffirming that:
1.b. The interpreter named in Part 4. read to me every
question and instruction on this application and my 1) I reviewed and understood all of the information
answer to every question in contained in, and submitted with, my application; and
, 2) All of this information was complete, true, and correct
a language in which I am fluent, and I understood at the time of filing.
everything. I certify, under penalty of perjury, that all of the information in
2. At my request, the preparer named in Part 5., my application and any document submitted with it were
Madeline Taylor Diaz provided or authorized by me, that I reviewed and understand
, all of the information contained in, and submitted with, my
prepared this application for me based only upon application and that all of this information is complete, true, and
information I provided or authorized. correct.

Applicant's Contact Information Applicant's Signature

3. Applicant's Daytime Telephone Number
7.a. Applicant's Signature

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

7.b. Date of Signature (mm/dd/yyyy)
5714194778
NOTE TO ALL APPLICANTS: If you do not completely fill
5. Applicant's Email Address (if any)
out this application or fail to submit required documents listed
in the Instructions, USCIS may deny your application.
6. Select this box if you are a Salvadoran or Guatemalan
national eligible for benefits under the ABC
Part 4. Interpreter's Contact Information,
settlement agreement.
Certification, and Signature

Provide the following information about the interpreter.

Interpreter's Full Name

1.a. Interpreter's Family Name (Last Name)

1.b. Interpreter's Given Name (First Name)

2. Interpreter's Business or Organization Name (if any)

Form I-765 Edition 07/26/22 Page 4 of 7

Part 4. Interpreter's Contact Information, Part 5. Contact Information, Declaration, and
Certification, and Signature Signature of the Person Preparing this
Application, If Other Than the Applicant
Interpreter's Mailing Address Provide the following information about the preparer.
3.a. Street Number
and Name Preparer's Full Name
3.b. Apt. Ste. Flr. 1.a. Preparer's Family Name (Last Name)
Taylor Diaz
3.c. City or Town
1.b. Preparer's Given Name (First Name)
3.d. State 3.e. ZIP Code
Madeline

3.f. Province 2. Preparer's Business or Organization Name (if any)

Taylor Diaz & Soltis PLLC
3.g. Postal Code

3.h. Country Preparer's Mailing Address

3.a. Street Number 200 Little Falls Street
and Name
Interpreter's Contact Information 3.b. Apt. Ste. Flr. 207
4. Interpreter's Daytime Telephone Number
3.c. City or Town Falls Church

5. Interpreter's Mobile Telephone Number (if any) 3.d. State VA 3.e. ZIP Code 22046

3.f. Province
6. Interpreter's Email Address (if any)
3.g. Postal Code

3.h. Country
Interpreter's Certification United States

I certify, under penalty of perjury, that:

Preparer's Contact Information
I am fluent in English and ,
which is the same language specified in Part 3., Item Number 4. Preparer's Daytime Telephone Number
1.b., and I have read to this applicant in the identified language 571-351-2227
every question and instruction on this application and his or her
answer to every question. The applicant informed me that he or 5. Preparer's Mobile Telephone Number (if any)
she understands every instruction, question, and answer on the
application, including the Applicant's Declaration and
Certification, and has verified the accuracy of every answer. 6. Preparer's Email Address (if any)
madeline@tdsimmigrationlaw.com
Interpreter's Signature
7.a. Interpreter's Signature

7.b. Date of Signature (mm/dd/yyyy)

Form I-765 Edition 07/26/22 Page 5 of 7

Part 5. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, If Other Than the Applicant
(continued)
Preparer's Statement
7.a. I am not an attorney or accredited representative
but have prepared this application on behalf of
the applicant and with the applicant's consent.
7.b. I am an attorney or accredited representative and
my representation of the applicant in this case
extends does not extend beyond the
preparation of this application.
NOTE: If you are an attorney or accredited
representative, you may need to submit a
completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited
Representative, with this application.

Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
prepared this application at the request of the applicant. The
applicant then reviewed this completed application and
informed me that he or she understands all of the information
contained in, and submitted with, his or her application,
including the Applicant's Declaration and Certification, and
that all of this information is complete, true, and correct. I
completed this application based only on information that the
applicant provided to me or authorized me to obtain or use.

Preparer's Signature
8.a. Preparer's Signature

8.b. Date of Signature (mm/dd/yyyy)

Form I-765 Edition 07/26/22 Page 6 of 7

 Part 6. Additional Information 5.a. Page Number 5.b. Part Number 5.c. Item Number

If you need extra space to provide any additional information

within this application, use the space below. If you need more 5.d.
space than what is provided, you may make copies of this page
to complete and file with this application or attach a separate
sheet of paper. Type or print your name and A-Number (if any)
at the top of each sheet; indicate the Page Number, Part
Number, and Item Number to which your answer refers; and
sign and date each sheet.
1.a. Family Name Vallecillo Burgalin
(Last Name)
1.b. Given Name Luis
(First Name)
1.c. Middle Name Alexander 6.a. Page Number 6.b. Part Number 6.c. Item Number

2. A-Number (if any) ► A-

6.d.
3.a. Page Number 3.b. Part Number 3.c. Item Number

3.d.

7.a. Page Number 7.b. Part Number 7.c. Item Number

7.d.

4.a. Page Number 4.b. Part Number 4.c. Item Number

4.d.

Form I-765 Edition 07/26/22 Page 7 of 7