OMB No. 1615-0040; Expires 02/28/2018

I-765, Application For
Employment Authorization

Department of Homeland Security
U.S. Citizenship and Immigration Services
Action Block

Fee Stamp

Initial Receipt

For
USCIS
Use
Only

Resubmitted

Relocated
Received

Sent

Completed
Eligibility under
8 CFR 274a.12
(a) or (c)

Authorization/Extension Valid From
Authorization/Extension Valid To

Economic necessity under
8 CFR 274a.12(c)(14), (18) and 8 CFR 214.2(f)

Subject to the following conditions:

I am applying for:
1.

A#

Applicant is filing under section 274a.12

(First Name)
KIRAN YADAV

2.
3.

U.S. Mailing Address
(Street Number and Name)
1660 LOBLOLLY COURT
(Town or City)
KENT

(Middle Name)

(Apt. Number)
322
(State)
(ZIP Code)
OH
44240

4.

Country of Citizenship or Nationality
INDIAN

5.

Place of Birth
(Town or City)
NASURULLABAD

(State/Province)
TELANGANA

6.

Date of Birth (mm/dd/yyyy)

7.

Gender

8.

Marital Status
Married
$

Male

(Country)
INDIA

01/15/1992

Divorced

(

c

) (

3

) (

B

)

17. (c)(3)(C) Eligibility Category. If you entered the eligibility category (c)(3)(C) in Question 16 above, list your degree, your employer's name as listed in E-Verify, and your employer's
E-Verify Company Identification Number or a valid E-Verify
Client Company Identification Number in the space below.
Degree
Employer's Name as listed in E-Verify
Employer's E-Verify Company Identification Number or a Valid
E-Verify Client Company Identification Number
18. (c)(26) Eligibility Category. If you entered the eligibility category (c)(26) in Question 16 above, please provide the receipt number of your H-1B principal spouse's most recent Form I-797
Notice of Approval for Form I-129.

Female

Single

15. Current Immigration Status (Visitor, Student, etc.)
Student
16. Eligibility Category. Go to the “Who May File Form I-765?” section of the Instructions. In the space below, place the letter and number of the eligibility category you selected from the instructions. For example, (a)(8), (c)(17)(iii), etc.

Other Names Used (include Maiden Name)

9.

Denied

Permission to accept employment.
Replacement (of lost employment authorization document).
Renewal of my permission to accept employment (attach a copy of your previous employment authorization document).

$

Full Name
(Family Name)
TOTAVARI

$

Approved

Application Denied - Failed to establish:

Application Approved

Widowed

Social Security Number (Include all numbers you have ever used, if any)
729-55-1963

10. Alien Registration Number (A-Number) or Form I-94 Number
(if any)
49599101930
11. Have you ever before applied for employment authorization from USCIS?
Yes (Complete the following questions.)
Which USCIS Office?
Dates

Certification
I certify, under penalty of perjury, 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 “Who May File
Form I-765?” section of the instructions and have identified the appropriate eligibility category in Question 16.
Applicant's SignatureDon't forget to sign!
Date of Signature (mm/dd/yyyy) 03/10/2016
Telephone Number (234) 303-5723
Signature of Person Preparing Form, If Other Than Applicant

Results (Granted or Denied - attach all documentation)
$

No (Proceed to Question 12.)

I declare that this document was prepared by me at the request of the applicant and is based on all information of which I have any knowledge. 12. Date of Last Entry into the U.S., on or about (mm/dd/yyyy)
01/06/2015

Preparer's Signature

13. Place of Last Entry into the U.S.
NEWARK, NEW JERSEY

Printed Name

Date of Signature (mm/dd/yyyy)
Address

14. Status at Last Entry (B-2 Visitor, F-1 Student, No Lawful
Status, etc.)
F-1 Student
Form I-765 11/04/15 Y