Immigration App

Information About You

Family Name (Last Name)

Given Name (First Name)

Middle Name (Middle Name)

Gender

Date of Birth dd/mm/yyyy

Information About You

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Physical Address

In care of Name

Apt./Ste./Flr

City or Town

State

ZIP Code

Postal Code

Province

Country

Information About You

Other Information

Country of Birth

Country of Citizenship

Country of Admission

Alien Registration Number (A-Number)

U.S. Social Security No. (if any)

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Application Type

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Please select the below that apply:

I am a permanent resident or conditional resident of the United States, and I am applying for a reentry permit.

I now hold U.S. refugee or asylee status, and I am applying for a Refugee Travel Document.

I am a permanent resident as a direct result of refugee or asylee status, and I am applying for a Refugee Travel Document.

I am applying for an Advance Parole Document to allow me to return to the United States after temporary foreign travel.

I am outside the United States, and I am applying for an Advance Parole Document.

I am applying for an Advance Parole Document for a person who is outside the United States.

Family Name (Last Name)

Given Name (First Name)

Middle Name (Middle Name)

Date of Birth (dd/mm/yyyy)

Country of Birth

Country of Citizenship

Daytime Phone Number

Application Type

Physical Address

In care of Name

Apt./Ste./Flr

City or Town

State

ZIP Code

Postal Code

Province

Country

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Processing Information

Date of Intended Departure(mm/dd/yyyy)

Expected Length of Trip(in days)

Are you, or any person included in this application, now in exclusion, deportation, removal, or rescission proceedings?

Yes

If "Yes", Name of DHS office:

Have you ever before been issued a reentry permit or Refugee Travel Document? (If "Yes" give the following information for the last document issued to you):

Yes

Date Issued dd/mm/yyyy

Disposition(attached, lost, etc.)

Note: If you are applying for a non-DACA related Advance Parole Document, skip to Part 7; DACA recipients must complete Part 4 before skipping to Part 7.

Processing Information

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Where do you want this travel document sent?

To the U.S. address shown in Part 1 (2.a through 2.i.) of this form.

To a U.S. Embassy or consulate at:

To a DHS office overseas at:

City or Town

Country

City or Town

Country

Processing Information

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Where should the notice to pick up the travel document be sent?

To an already entered address

To another address

Physical Address

In care of Name

Apt./Ste./Flr

City or Town

State

ZIP Code

Postal Code

Province

Country

Processing Information

Perv

Purpose of trip

List the countries you intend to visit.

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Complete Only If Applying for a Refugee Travel Document

On a separate sheet of paper, explain how you qualify for an Advance Parole Document, and what circumstances warrant issuance of advance parole. Include copies of any documents you wish considered.

How many trips do you intend to use this document?

One Trip

More than one trip

Note: If the person intended to receive an Advance Parole Document is outside the United States, provide the location (City or Town and Country) of the U.S. Embassy or consulate or the DHS overseas office that you want us to notify.

Where do you want this travel document sent?

To the U.S. address shown in Part 1 (2.a through 2.i.) of this form.

To a U.S. Embassy or consulate at:

To a DHS office overseas at:

City or Town

Country

City or Town

Country

If the travel document will be delivered to an overseas office, where should the notice to pick up the document be sent?:

Complete Only If Applying for a Refugee Travel Document

Processing Information

Date of Intended Departure(mm/dd/yyyy)

Expected Length of Trip(in days)

Are you, or any person included in this application, now in exclusion, deportation, removal, or rescission proceedings?

Yes

If "Yes", Name of DHS office:

Have you ever before been issued a reentry permit or Refugee Travel Document? (If "Yes" give the following information for the last document issued to you):

Yes

Date Issued dd/mm/yyyy

Disposition(attached, lost, etc.)

If you are applying for a non-DACA related Advance Parole Document, skip to Part 7; DACA recipients must complete Part 4 before skipping to Part 7.

Signature of Applicant

Note: (Read the information on penalties in the Form instructions before completing this Part.) If you are filing for a Re-entry Permit or Refugee Travel Document, you must be in the United States to file this application.

I agree written. Certify, under penalty of perjury under the laws of the United States of America, that this application and the evidence submitted with it is all true and correct. I authorize the release of any information from my records that U.S. Citizenship and Immigration Services needs to determine eligibility for the benefit I am seeking.

Signature

Date of Signature

Daytime Phone Number

Note: If you do not completely fill out this form or fail to submit required documents listed in the instructions, your application may be denied.

Who is this application being submitted for?

Self

On someone's behalf

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Information About Person Who Prepared This Application, If Other Than the Applicant

Preparer's Full Name

NOTE: If you are an attorney or representative, you must submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, along with this application.

Provide the following information concerning the preparer:

Preparer's Family Name (Last Name)

Preparer's Given Name (First Name)

Preparer's Business or Organization Name

Information About Person Who Prepared This Application, If Other Than the Applicant

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Preparer's Mailing Address

In care of Name

Apt./Ste./Flr

City or Town

State

ZIP Code

Postal Code

Province

Country

Information About Person Who Prepared This Application, If Other Than the Applicant

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Preparer's Contact Information

Preparer's Daytime Phone Number

Preparer's E-mail Address (if any)

Information About Person Who Prepared This Application, If Other Than the Applicant

Declaration

I agree written. To be completed by all preparers, including attorneys and authorized representatives: I declare that I prepared this benefit request at the request of the applicant, that it is based on all the information of which I have knowledge, and that the information is true to the best of my knowledge.

Signature of Preparer

Date of Signature

Note If you require more space to provide any additional information, use a separate sheet of paper. You must include your Name and A-Number on the top of each sheet.

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Information About You

Information About You

Physical Address

Information About You

Other Information

Application Type

Application Type

Physical Address

Processing Information

Processing Information

Processing Information

Physical Address

Processing Information

Complete Only If Applying for a Re-entry Permit

Complete Only If Applying for a Refugee Travel Document

Complete Only If Applying for a Refugee Travel Document

Complete Only If Applying for a Refugee Travel Document

Processing Information

If you are applying for a non-DACA related Advance Parole Document, skip to Part 7; DACA recipients must complete Part 4 before skipping to Part 7.

Signature of Applicant

Information About Person Who Prepared This Application, If Other Than the Applicant

Preparer's Full Name

Information About Person Who Prepared This Application, If Other Than the Applicant

Preparer's Mailing Address

Information About Person Who Prepared This Application, If Other Than the Applicant

Preparer's Contact Information

Information About Person Who Prepared This Application, If Other Than the Applicant

Declaration