Escolar Documentos
Profissional Documentos
Cultura Documentos
USCIS
Form I-90
OMB No. 1615-0082
Expires 10/31/2017
Receipt
Action Block
Date:
Class of Admission
For
USCIS
Use
Only Remarks
DRAFT
Not for
Reproduction
06/09/2015
A-
2.
Mailing Address
Apt.
Ste.
Flr.
6.f.
ZIP Code
6.g. Province
6.h. Postal Code
6.i.
Country
Page 1 of 8
Physical Address
Apt.
Ste.
Flr.
1.a.
DRAFT
Not for
Reproduction
06/09/2015
1.b.
1.c.
Province
Additional Information
8.
Gender
9.
Date of Birth
10.
City/Town/Village of Birth
11.
Country of Birth
Male
Female
(mm/dd/yyyy)
2.a.
2.b.
2.c.
2.d.
2.e.
2.f.
2.g1.
2.g2.
Mother's Name
Given Name
(First Name)
Father's Name
12.
13.
14.
15.
16.
Given Name
(First Name)
Class of Admission
Date of Admission
(mm/dd/yyyy)
U.S. Social Security Number (if any)
Page 2 of 8
2.h1.1.
4.
2.h2.
2.i.
2.j.
DRAFT
Not for
Reproduction
06/09/2015
3.b.
3.c.
3.d.
3.e.
5.
No
Biographic Information
6.
7.
2.
8.
Height
9.
Weight
10.
11.
Feet
Inches
Pounds
Black
Gray
Blue
Brown
Green
Hazel
Maroon
Pink
Unknown/Other
Black
Gray
White
Blond
Red
Unknown/Other
Page 3 of 8
Applicant's Statement
DRAFT
Not for
Reproduction
06/09/2015
1.b.
1.c.
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
1.a.
1.b.
2.
is
is not an attorney or accredited
who
representative, preparing this application for me.
This person who assisted me in preparing my
application has reviewed the Acknowledgement of
Appointment at USCIS Application Support
Center with me, and I understand the ASC
Acknowledgement.
Page 4 of 8
4.
5.
Applicant's Certification
Copies of any documents I have submitted are exact photocopies
of unaltered, original documents, and I understand that USCIS
may require that I submit original documents to USCIS at a later
date. Furthermore, I authorize the release of any information
from any and all of my records that USCIS may need to
determine my eligibility for the immigration benefit I seek.
I furthermore authorize release of information contained in this
application, in supporting documents, and in my USCIS records
to other entities and persons where necessary for the
administration of U.S. immigration laws.
DRAFT
Not for
Reproduction
06/09/2015
I,
,
understand that the purpose of a USCIS ASC appointment is
for me to provide fingerprints, photograph, and/or signature
and to re-affirm that all of the information in my application
is complete, true, and correct and was provided by me. I
understand that I will sign my name to the following
declaration which USCIS will display to me at the time I
provide my fingerprints, photograph, and/or signature during
my ASC appointment:
Applicant's Signature
2.
Page 5 of 8
Apt.
Ste.
Flr.
DRAFT
Not for
Reproduction
06/09/2015
3.e. ZIP Code
Province
5.
Interpreter's Signature
Interpreter's Certification
I certify that:
2.
Page 6 of 8
7.a.
7.b.
Apt.
Ste.
Flr.
DRAFT
Not for
Reproduction
06/09/2015
Preparer's Statement
Province
Preparer's Certification
5.
6.
Preparer's Signature
Page 7 of 8
4.d.
DRAFT
Not for
Reproduction
06/09/2015
A-
3.d.
5.d.
Page 8 of 8