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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 .
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Application for Civil Surgeon Designation Department of Homeland Security U.S. Citizenship and Immigration Services Initial Receipt For Resubmitted USCIS Relocated Use Received Sent Only Remarks Barcode USCIS Form I-910 OMB No. 1615-0114 Expires 10/31/2015 Action Block CSID Number: To Be Completed by an Attorney or Accredited Representative, if any. START HERE - Type or print in black ink. Select the box if Form G-28 is attached to represent the applicant. Attorney State License Number: Part 1. For Previously Designated Civil Surgeons 1.a. Have you ever been designated as a civil surgeon before? Yes If you selected "Yes," provide the following information: 1.b. Period of Designation (mm/dd/yyyy) From To No Part 2. Information About You (Physician requesting designation or renewal) Your Full Name 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 1.c. USCIS Office that granted the designation 1.d. Civil Surgeon Identification Number (if known) Other Information 2. Date of Birth (mm/dd/yyyy) 2.a. Has USCIS ever revoked your designation? Yes If you selected "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 selected "Yes," provide the following information: 3.b. Date of Voluntary Termination (mm/dd/yyyy) NOTE: If you select "Yes" to Item Number 2.a. or 3.a. above, please include a written explanation of the circumstances surrounding the revocation or voluntary termination, in a separate letter attached to this application or in Part 10., Additional Information. No No Part 3. Clinical Office Location(s) 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 Part 10., Additional Information. A. Required Information You must provide the following information. Failure to provide this information may result in the denial of your application. Please refer to Part 2., Section B for more information about what will be made publicly available. 1. Name of Clinic/Practice Form I-910 10/22/13 Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Part 3. Clinical Office Locations (continued) Physical Address of the Clinic/Practice 2.a. Street Number and Name 2.b. Apt. Ste. Flr. 6. Other 2.c. City or Town 2.d. State 3. 2.e. ZIP Code Part 4. 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. 1. I am a U.S. citizen or national (Attach proof that you are a U.S. citizen, such as a copy of a U.S. passport, birth certificate, or Certificate of Naturalization.) I am a Legal Permanent Resident (Attach a copy of your valid Form I-551, Permanent Resident Card. If you are currently seeking to extend your Form I-551, attach evidence thereof.) I am currently present in the United States as a nonimmigrant (Provide 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.) Telephone Number 4. Fax Number 2. 5. E-Mail 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 form 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. 3. B. Optional Information Providing the following information is optional. Your application will not be affected if you choose not to provide this information. If and when feasible, USCIS may provide this information, in addition to the required information above, as part of the public civil surgeon list. To submit additional information, please check the relevant boxes below and provide the requested details: 1. E-Mail Address (For use by the public) 3.a. Date of Last Arrival (mm/dd/yyyy) in the U.S. 3.b. Form I-94 Arrival/ Departure Record Number (If any) 3.c. Passport Number 3.d. Travel Document Number 3.e. Country of Issuance for Passport or Travel Document 2. Web Site Address (URL) 3.f. Expiration Date for Passport or Travel Document (mm/dd/yyyy) 3.g. Current Nonimmigrant Status 3. Fees for Medical Examination 4. Acceptable Means of Payment 5. Languages Spoken Form I-910 10/22/13 Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Part 4. Information About Your Status in the United States (continued) 4. Other status granted that would allow you to practice medicine in the United States: School 1: 1.a. School 1.b. Dates of Attendance (mm/dd/yyyy) From 1.c. Degree To School 2: 2.a. School Part 5. Medical License(s) 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 the medical license(s) listed below. Medical License 1: 1.a. State U.S. Territory 1.b. Medical License Number OR 2.b. Dates of Attendance (mm/dd/yyyy) From 2.c. Degree To Part 7. Professional Experience You must establish at least 4 years of professional experience to be eligible for designation. NOTE: Time spent in a post-medical school training (including internships or residency programs) cannot be counted toward this experience requirement. Please attach evidence to verify your professional experience, such as evaluations, certificates of completion, or letters of employment verification. Employer 1: 1.a. Employer 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 1.b. Dates of Employment (mm/dd/yyyy) From 1.c. Contact Information To Employer 2: 2.c. Date Issued (mm/dd/yyyy) 2.a. Employer 2.d. Date Expires (mm/dd/yyyy) 2.b. Dates of Employment (mm/dd/yyyy) From 2.c. Contact Information To Part 6. Medical Degree(s) You must be a Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) to be eligible for civil surgeon designation. Attach a copy of the medical degree(s) listed below. Form I-910 10/22/13 Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Part 8. Signature of Applicant By signing this form
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