Application for Civil Surgeon Designation

• Legal Form Number: I-910
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

Page 1 of 9Form I-910 Edition 11/02/22

To be completed by an

attorney or accredited

representative (if any).

For

USCIS

Use

Only

Application for Civil Surgeon Designation

Department of Homeland Security

U.S. Citizenship and Immigration Services

START HERE - Type or print in black ink.►

USCIS

Form I-910

OMB No. 1615-0114

Expires 11/30/2025

Action Block

Sent

Received

Initial Receipt Barcode

Resubmitted

Remarks

Part 1. Information About You (The Applicant)

1.

Have you ever been designated as a civil surgeon?

If you answered "Yes" to Item Number 1., provide the following information.

Period of Designation (mm/dd/yyyy)3.Civil Surgeon Identification Number (CSID) (if known)

Yes No

2.

From To

4. Has USCIS ever revoked your designation? Yes No

Date of Revocation (mm/dd/yyyy)5.

If you answered "Yes" to Item Number 4., provide the following information.

6.

Have you ever voluntarily terminated your designation?

If you answered "Yes" to Item Number 6., provide the following information.

Yes No

CSID Number

NOTE: If you answered "Yes" to Item Number 4. or Item Number 6., include a typed or printed explanation of the circumstances

surrounding the revocation or voluntary termination in Part 10. Additional Information.

Date of Voluntary Termination (mm/dd/yyyy)7.

Family Name (Last Name) Given Name (First Name) Middle Name (if applicable)

8. Your Full Legal Name (Do not provide a nickname)

Attorney State Bar Number

(if applicable)

Select this box if

Form G-28 is

attached.

Attorney or Accredited Representative

USCIS Online Account Number (if any)