OMB No. ****-****; Expires **/**/****

I-***, Application For

Department of Homeland Security

Employment Authorization

U.S. Citizenship and Immigration Services

Do not write in this block.

Action Block Fee Stamp

Remarks

A#

Applicant is filing under 274a.12

until (Date).

Application Approved. Employment Authorized / Extended (Circle One)

(Date).

Subject to the following conditions:

Application Denied.

Failed to establish eligibility under 8 CFR 274a.12 (a) or (c).

Failed to establish economic necessity under 8 CFR 274a.12(c)(14), (18) and 8 CFR 214.2(f)

I am applying for: Permission to accept employment.

Replacement (of lost employment authorization document).

Renewal of my permission to accept employment (attach previous employment authorization document).

Which USCIS Office? Date(s)

1. Name (Family Name in CAPS) (First) (Middle)

Arlington asylum office

Tekle Berhane Lekwe

Results (Granted or Denied - attach all documentation)

2. Other Names Used (include Maiden Name)

12. Date of Last Entry into the U.S., on or about: (mm/dd/yyyy)

3. U.S. Mailing Address (Street Number and Name) (Apt. Number)

11/29/99

8860 piney Branch Rd 910

13. Place of Last Entry into the U.S.

(Town or City) (State/Country) (ZIP Code)

Newark New jersey

Silver spring MD 20903

14. Status at Last Entry (B-2 Visitor, F-1 Student, No Lawful Status, etc.)

4. Country of Citizenship/Nationality

H4 visa

Ethiopian

15. Current Immigration Status (Visitor, Student, etc.)

5. Place of Birth (Town or City) (State/Province) (Country)

Asylee

Nazareth show

16. Go to the Who May File Form I-765? section of the instructions. In the

7. Gender

6. Date of Birth (mm/dd/yyyy)

space below, place the letter and number of the eligibility category you

03/14/1970 Male Female selected from the instructions. (For example, (a)(8), (c)(17)(iii), etc.).

8. Marital Status Single

Married

(a (s )

) ) (

Widowed Divorced

17. If you entered the eligibility category, (c)(3)(C), in Question 16 above, list your

9. Social Security Number (Include all numbers you have ever used, if any)

degree, your employer's name as listed in E-Verify, and your employer's E-

216 73 6716

Verify Company Identification Number or a valid E-Verify Client Company

10. Alien Registration Number (A-Number) or I-94 Number (if any) Identification Number in the space below.

A97-919-515 Degree:

11. Have you ever before applied for employment authorization from USCIS? Employer's Name as listed in E-Verify:

No (Proceed to

Yes (Complete the following Employer's E-Verify Company Identification Number or a valid E-Verify

questions.) Question 12.) Client Company Identification Number

Certification

Your Certification: I certify, under penalty of perjury under the laws of the United States of America, 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.

Signature Telephone Number Date

301-***-**** 6/25/2014

Signature of Person Preparing Form, If Other Than Above: 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.

Signature

Address Date

Print Name

Relocated

Initial Receipt Resubmitted Completed

Remarks

Returned

Approved

Received Sent Denied

Form I-765 04/01/13 Y

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