Official Federal Forms > US Citizenship And Immigration Services

Application For Civil Surgeon Designation I-910 - Official Federal Forms

Application For Civil Surgeon Designation Form. This is a national form and can be used in US Citizenship And Immigration Services .
 Fillable pdf Last Modified 2/14/2014
Get this form for FREE as a print-only pdf

Application for Civil Surgeon Designation Department of Homeland Security U.S. Citizenship and Immigration Services Initial Receipt (mm/dd/yyyy) For Resubmitted (mm/dd/yyyy) USCIS Received Sent Use Only Remarks Barcode OMB No. 1615-0114 Expires 05/31/2018 USCIS Form I-910 Action Block CSID Number: To be completed by an attorney or accredited representative (if any). Select this box if Form G-28 is attached to represent the applicant. Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS Online Account Number (if any) START HERE - Type or print in black ink. Part 1. Information About You 1.a. Have you ever been designated as a civil surgeon? Yes If you answered "Yes," provide the following information. 1.b. Period of Designation (mm/dd/yyyy) From To 1.c. U.S. Citizenship and Immigration Services (USCIS) office that granted the designation 1.d. Civil Surgeon Identification Number (CSID) (if known) No NOTE: If you answered "Yes" to Item Numbers 2.a. or 3.a. above, include a typed or printed explanation of the circumstances surrounding the revocation or voluntary termination in Part 9. Additional Information. Your Full Name 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name Other Names Used List all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provide in Part 9. Additional Information. 5.a. Family Name (Last Name) 5.b. Given Name (First Name) 5.c. Middle Name 2.a. Has USCIS ever revoked your designation? Yes If you answered "Yes," provide the following information. 2.b. Date of Revocation (mm/dd/yyyy) 3.a. Have you ever voluntarily terminated your designation? Yes If you answered "Yes," provide the following information. 3.b. Date of Voluntary Termination (mm/dd/yyyy) No No Other Information 6. 7. 8. Date of Birth (mm/dd/yyyy) Gender Male Female USCIS Online Account Number (if any) American LegalNet, Inc. www.FormsWorkFlow.com Form I-910 05/10/16 N Page 1 of 7 Part 2. Clinical Office Locations Provide the following information about the locations where you seek to perform immigration medical examinations. If you seek to perform immigration medical exams in more than one location, provide the details for each additional location in the space provided in Part 9. Additional Information. 7. Web site Address (URL) 8. Fees for Medical Examination 9. Acceptable Means of Payment A. Required Information You must provide the following information. Failure to provide this information may result in the denial of your application. Refer to Part 2., Section B for more information about what will be made publicly available. 1. Name of Clinic/Practice 10. Accepted Medical Insurance Plans 11. Languages Spoken Physical Address of the Clinic/Practice 2.a. Street Number and Name 2.b. Apt. Ste. Flr. 13. 2.e. ZIP Code 14. Other Handicap Accessibility 12. Office Hours 2.c. City or Town 2.d. State 3. 4. 5. Telephone Number Fax Number Email Address (For use by USCIS) NOTE: USCIS will use the contact information listed above for all civil surgeon-related communication. UPDATE USCIS OF ANY CHANGES: Civil surgeons are responsible for notifying USCIS in writing of any updates to the contact information provided in this application within 15 days of the change. Visit the USCIS Web site at www.uscis.gov/I-910 for information on how to submit a change. Part 3. Information About Your Status in the United States You must be authorized to work in the United States to be eligible for civil surgeon designation. Select the box that accurately states how you are authorized to work in the United States. 1. I am a U.S. citizen or national (Attach proof that you are a U.S. citizen or national, such as a copy of a U.S. passport, birth certificate, or Certificate of Naturalization.) I am a Lawful Permanent Resident. (Attach a copy of your valid Form I-551, Permanent Resident Card. If you are currently seeking to renew or replace your Form I-551, attach evidence showing that you are doing so.) B. Additional Office Information Your application will not be affected if you choose not to provide the following information. USCIS displays this information on our Web site for people who want to find a civil surgeon. 6. Email Address (For use by the public) 2. Form I-910 05/10/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 7 Part 3. Information About Your Status in the United States (continued) 3. I am currently present in the United States as a nonimmigrant (Attach a copy of your Form I-94 Arrival-Departure Record, a copy of your passport or travel document, and any documents related to your nonimmigrant status, such as a copy of the petition, petition approval, and change or extension of status application. Also attach a copy of your valid, unexpired Employment Authorization Document as proof of your authorization to work in the United States, if required.) Part 4. Medical Licenses You must be licensed to practice medicine in the state or territory in which you seek to perform immigration medical examinations to be eligible for civil surgeon designation. Attach a copy of each medical license listed below. If you need extra space to complete this section, use the space provided in Part 9. Additional Information. Medical License 1 1.a. State U.S. Territory 1.b. Medical License Number OR 4.a. Date of Last Arrival in the U.S. (mm/dd/yyyy) 4.b. Form I-94 Arrival-Departure Record Number (if any) 4.c. Passport Number 4.d. Travel Document Number 4.e. Country of Issuance for Passport or Travel Document 4.f. Expiration Date for Passport or Travel Document (mm/dd/yyyy) 4.g. Current Nonimmigrant Status 1.c. Date Issued (mm/dd/yyyy) 1.d. Date Expires (mm/dd/yyyy) Medical License 2 2.a. State U.S. Territory 2.b. Medical License Number OR 2.c. Date Issued (mm/dd/yyyy) 2.d. Date Expires (mm/dd/yyyy) 5. I have been granted another status under U.S. immigration law that allows me to work and to practice medicine in the United States: Part 5. Medical Degrees You must possess a medical degree as a Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) to be eligible for civil surgeon designation. Attach a copy of each medical degree listed below. If you need extra space to complete this section, use the space provided in Part 9. Additional Information. School 1 1.a. School Name 1.b. Dates of Attendance (mm/dd/yyyy) From 1.c. Degree To Form I-910 05/10/16 N American LegalNet, Inc. ww
Link/Embed this Document
URL
Embed


Popular Searches

  1. stipulation of discontinuance
  2. deposition subpoena
  3. bill of costs
  4. durable power of attorney
  5. Request for entry of default
  6. Form Interrogatories-General
  7. Preliminary Change of Ownership Report
  8. Decree of Dissolution of Marriage
  9. proof of service of summons
  10. fee waiver

Bookmark and Share