Form I-905 - Application For Authorization To Issue Certification For Health Care Workers Page 3
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1
2
3Preparer's Mailing Address
Part 3. Contact Information, Certification, and
Signature of the Interpreter (continued)
3.a.
Street Number
and Name
Interpreter's Contact Information
3.b.
Apt.
Ste.
Flr.
4.
Interpreter's Daytime Telephone Number
3.c. City or Town
3.d. State
3.e. ZIP Code
5.
Interpreter's E-mail Address
Preparer's Contact Information
4.
Preparer's Daytime Telephone Number
Interpreter Certification
I certify that:
5.
Preparer's Fax Number
I am fluent in English and
,
which is the same language provided in Part 2.,
Item Number 1.b.;
6.
Preparer's E-mail Address
I have read to this applicant each and every question and
instruction on this form, as well as the answer to each question,
in the language provided in Part 2., Item Number 1.b.; and
I am not an attorney or accredited representative but
7.a.
The applicant has informed me that he or she understands each
have prepared this form on behalf of the applicant
and every instruction and question on the form, as well as the
and with the applicant's consent.
answer to each question.
I am an attorney or accredited representative and my
7.b.
representation of the applicant in this case
6.a.
Interpreter's Signature
(choose one) extends
does not extend
beyond the preparation of this form.
►
6.b.
Date of Signature
(mm/dd/yyyy)
Preparer's Declaration
By my signature, I certify, swear, or affirm, under penalty of
Part 4. Contact Information, Declaration, and
perjury, that I prepared this form on behalf of, at the request of,
Signature of the Person Preparing this
and with the express consent of the applicant. I completed the
Application, If Other than the Applicant
form based only on responses the applicant provided to me.
After completing the form, I reviewed it and all of the
applicant's responses with the applicant, who agreed with each
Preparer's Full Name
and every answer provided for each question on the form and,
when required, supplied additional information to respond to a
Provide the following information concerning the preparer:
question on the form.
1.a. Preparer's Family Name (Last Name)
8.a. Preparer's Signature
1.b.
Preparer's Given Name (First Name)
8.b. Date of Signature (mm/dd/yyyy) ►
NOTE: If you do not completely fill out this form or fail to
2.
Preparer's Business or Organization Name
submit required documents listed in the instructions, this
application may be denied.
Page 3 of 3
Form I-905 02/11/14 Y
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