Form G-** **/**/** Page * of *

Notice of Entry of Appearance

as Attorney or Accredited Representative

Department of Homeland Security

Part 1. Information About Attorney or

Accredited Representative

Name of Attorney or Accredited Representative

4.

5.

2.a. Family Name

(Last Name)

2.b. Given Name

(First Name)

2.c. Middle Name

Daytime Telephone Number

DHS

Form G-28

OMB No. 1615-0105

Expires 05/31/2021

1. USCIS Online Account Number (if any)

Ź

Street Number

and Name

3.a.

3.b. Apt. Ste. Flr.

3.c. City or Town

3.d. State 3.e. ZIP Code

3.f. Province

3.g. Postal Code

3.h. Country

Email Address (if any)

7. Fax Number (if any)

6.

2.b. Name of Recognized Organization

2.c. Date of Accreditation (mm/dd/yyyy)

2.a. I am an accredited representative of the following qualified nonprofit religious, charitable, social

service, or similar organization established in the United States and recognized by the Department of

Justice in accordance with 8 CFR part 1292.

1.c. I (select only one box) am not am

subject to any order suspending, enjoining, restraining, disbarring, or otherwise restricting me in the practice of law. If you are subject to any orders, use the space provided in Part 6. Additional Information to provide an explanation.

1.b. Bar Number (if applicable)

Part 2. Eligibility Information for Attorney or

Accredited Representative

Select all applicable items.

1.a. I am an attorney eligible to practice law in, and a member in good standing of, the bar of the highest courts of the following states, possessions, territories, commonwealths, or the District of Columbia. If you need extra space to complete this section, use the space provided in Part 6. Additional Information.

Contact Information of Attorney or Accredited

Representative

3. I am associated with

the attorney or accredited representative of record who previously filed Form G-28 in this case, and my appearance as an attorney or accredited representative for a limited purpose is at his or her request.

,

4.a. I am a law student or law graduate working under the direct supervision of the attorney or accredited

representative of record on this form in accordance with the requirements in 8 CFR 292.1(a)(2).

4.b. Name of Law Student or Law Graduate

Licensing Authority

Mobile Telephone Number (if any)

Address of Attorney or Accredited Representative

1.d. Name of Law Firm or Organization (if applicable)

(USPS ZIP Code Lookup)

Form G-28 09/17/18 Page 2 of 4

I enter my appearance as an attorney or accredited representative at the request of the (select only one box): 5.

Applicant Petitioner Requestor

Respondent (ICE, CBP)

2.a. U.S. Immigration and Customs Enforcement (ICE) 2.b. List the specific matter in which appearance is entered. 3.a. U.S. Customs and Border Protection (CBP)

3.b. List the specific matter in which appearance is entered. 1.a. U.S. Citizenship and Immigration Services (USCIS) List the form numbers or specific matter in which

appearance is entered.

1.b.

Part 3. Notice of Appearance as Attorney or

Accredited Representative

This appearance relates to immigration matters before

(select only one box):

Beneficiary/Derivative

Information About Client (Applicant, Petitioner,

Requestor, Beneficiary or Derivative, Respondent,

or Authorized Signatory for an Entity)

6.a. Family Name

(Last Name)

6.b. Given Name

(First Name)

6.c. Middle Name

7.a. Name of Entity (if applicable)

11. Mobile Telephone Number (if any)

9. Client's Alien Registration Number (A-Number) (if any) 8. Client's USCIS Online Account Number (if any)

Ź

13.f. Province

13.g. Postal Code

13.h. Country

13.a. Street Number

and Name

13.c. City or Town

13.d. State 13.e. ZIP Code

13.b. Apt. Ste. Flr.

NOTE: Provide the client's mailing address. Do not provide the business mailing address of the attorney or accredited representative unless it serves as the safe mailing address on the application or petition being filed with this Form G-28. Mailing Address of Client

12. Email Address (if any)

Ź A-

4. Receipt Number (if any)

10. Daytime Telephone Number

Client's Contact Information

7.b. Title of Authorized Signatory for Entity (if applicable) Ź

Part 4. Client's Consent to Representation and

Signature

I have requested the representation of and consented to being represented by the attorney or accredited representative named in Part 1. of this form. According to the Privacy Act of 1974 and U.S. Department of Homeland Security (DHS) policy, I also consent to the disclosure to the named attorney or accredited representative of any records pertaining to me that appear in any system of records of USCIS, ICE, or CBP. Consent to Representation and Release of

Information

If you need extra space to complete this section, use the space provided in Part 6. Additional Information.

Form G-28 09/17/18 Page 3 of 4

Part 4. Client's Consent to Representation and

Signature (continued)

Part 5. Signature of Attorney or Accredited

Representative

I have read and understand the regulations and conditions contained in 8 CFR 103.2 and 292 governing appearances and representation before DHS. I declare under penalty of perjury under the laws of the United States that the information I have provided on this form is true and correct.

1. a. Signature of Attorney or Accredited Representative 2.a. Signature of Law Student or Law Graduate

2.b. Date of Signature (mm/dd/yyyy)

I request that USCIS send original notices on an

application or petition to the business address of my attorney or accredited representative as listed in this form.

1.a.

If you want to have notices and/or secure identity documents sent to your attorney or accredited representative of record rather than to you, please select all applicable items below. You may change these elections through written notice to USCIS. 1.b. Date of Signature (mm/dd/yyyy)

USCIS will send notices to both a represented party (the client) and his, her, or its attorney or accredited representative either through mail or electronic delivery. USCIS will send all secure identity documents and Travel Documents to the client's U.S. mailing address.

Options Regarding Receipt of USCIS Notices and

Documents

I request that USCIS send any secure identity

document (Permanent Resident Card, Employment

Authorization Document, or Travel Document) that I receive to the U.S. business address of my attorney or accredited representative (or to a designated military or diplomatic address in a foreign country (if

permitted)).

1.b.

NOTE: If your notice contains Form I-94,

Arrival-Departure Record, USCIS will send the

notice to the U.S. business address of your attorney or accredited representative. If you would rather

have your Form I-94 sent directly to you, select

Item Number 1.c.

I request that USCIS send my notice containing Form I-94 to me at my U.S. mailing address.

1.c.

2.a. Signature of Client or Authorized Signatory for an Entity 2.b. Date of Signature (mm/dd/yyyy)

Signature of Client or Authorized Signatory for an Entity

Form G-28 09/17/18 Page 4 of 4

Part 6. Additional Information

If you need extra space to provide any additional information within this form, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this form or attach a separate sheet of paper. Type or print your name at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. 2.d.

1.a Family Name

(Last Name)

1.b. Given Name

(First Name)

1.c. Middle Name

2.a. Page Number 2.b. Part Number 2.c.

3.d.

3.a. Page Number 3.b. Part Number 3.c. Item Number Page Number Part Number Item Number

Page Number Part Number Item Number

Page Number Part Number Item Number

Item Number

4.b. 4.c.

4.d.

4.a.

5.d.

5.a. 5.b. 5.c.

6.b. 6.c.

6.d.

6.a.

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