Form I-905 - Application For Authorization To Issue Certification For Health Care Workers
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2OMB No. 1615-0086; Expires 10/31/2012
I-905, Application for Authorization to
Department of Homeland Security
Issue Certification for Health Care Workers
U.S. Citizenship and Immigration Services
For USCIS Use Only
START HERE -
Please type or print in black ink.
Part 1.
Information About the Applicant Filing This Form
Returned
Receipt
Company or Organization
Address
Resubmitted
Street Number and Name
Room #
City
State
Zip/Postal Code
IRS Tax #
Name of Point of Contact
Reloc Sent
Phone # of Point of Contact
Title of Point of Contact
Date organization was created.
Reloc Rec'd
Description of your organization.
Approved for all requested
occupations.
Partial approval (USCIS must list
approved occupations.)
Occupations for which you are seeking authorization.
Action Block
Describe the process you will use to issue certificates. (If more space is required,
use a separate sheet of paper.)
To Be Completed by
Explain your organization's expertise, knowledge, and experience in the health
Attorney or Representative, if any
care occupations for which you are seeking authorization.
Fill in box if Form G-28 is attached to
represent the petitioner
VOLAG#
ATTY State License #
Form I-905 (10/30/11) Y
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