Application for Authorization to Issue Certification for Health Care Workers

• Legal Form Number: I-905
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

Form I-905 11/10/20

Returned Receipt

Resubmitted

Reloc Sent

Reloc Rec'd

For

USCIS

Use

Only

USCIS

Form I-905

Approved for all requested

occupations.

Partial approval (USCIS must list

approved occupations.)

Action Block

To Be Completed by

Attorney or Representative, if any

Select the box if Form G-28 is

attached to represent the applicant

ATTY State License Number

VOLAG#

START HERE - Please type or print in black ink.

1. Name of Company or Organization

Part 1. Information About the Applicant Filing

This Form

►

Address

ZIP Code

2.e.

State

2.d.

City or Town

3.

5.

Point of Contact

Title

IRS Tax Number

2.c.

Street Number

and Name

2.a.

►(mm/dd/yyyy)

Date the organization was created.6.

Description of your organization.

Describe the process you will use to issue certificates.

Occupations for which you are seeking authorization.

Application for Authorization to Issue Certification

for Health Care Workers

Department of Homeland Security

U.S. Citizenship and Immigration Services

4.b.

4.c.

4.a. Family Name

(Last Name)

Given Name

(First Name)

Middle Name

Flr.Ste.

Apt.

2.b.

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