Fillable Printable Form I-910
Fillable Printable Form I-910
Form I-910
Page 1 of 7Form I-910 12/23/16 N
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 05/31/2018
Action Block
SentReceived
Initial Receipt (mm/dd/yyyy)
Barcode
Resubmitted (mm/dd/yyyy)
Remarks
Part 1. Information About You
1.a.
Have you ever been designated as a civil surgeon?
If you answered "Yes," provide the following information.
U.S. Citizenship and Immigration Services
(USCIS)
office that granted the designation
Period of Designation (mm/dd/yyyy)1.b.
1.c.
Civil Surgeon Identification Number (CSID) (if known)
1.d.
From
To
Yes No
2.a.
Has USCIS ever revoked your designation?
Yes No
Date of Revocation2.b.
If you answered "Yes," provide the following information.
(mm/dd/yyyy)
3.a.
Have you ever voluntarily terminated your designation?
If you answered "Yes," provide the following information.
Date of Voluntary Termination (mm/dd/yyyy)3.b.
Yes
No
NOTE: If you answered "Yes" to Item Numbers 2.a. or 3.a.
above, include a typed or printed explanation of the
circumstances surrounding the revocation or voluntary
termination in Part 9. Additional Information.
Your Full Name
Other Names Used
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c.
Middle Name
Date of Birth (mm/dd/yyyy)6.
Other Information
CSID Number:
Select this box if
Form G-28 is
attached to represent
the applicant.
Attorney State Bar Number
(if applicable)
Attorney or Accredited Representative
USCIS Online Account Number (if any)
USCIS Online Account Number (if any)8.
►
7. Gender Male
Female
Middle Name
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c.
List all other names you have ever used, including aliases,
maiden name, and nicknames. If you need extra space to
complete this section, use the space provide in Part 9.
Additional Information.
Page 2 of 7Form I-910 12/23/16 N
2.c.
2.d.
City or Town
State
2.e.
ZIP Code
Street Number
and Name
2.a.
2.b.
Apt.
Flr.Ste.
Telephone Number3.
4. Fax Number
Email Address (For use by USCIS)5.
NOTE: USCIS will use the contact information listed above
for all civil surgeon-related communication.
UPDATE USCIS OF ANY CHANGES: Civil surgeons are
responsible for notifying USCIS in writing of any updates to the
contact information provided in this application within 15 days
of the change. Visit the USCIS Website at
www.uscis.gov/I-910
for information on how to submit a
change.
Physical Address of the Clinic/Practice
B. Additional Office Information
Your application will not be affected if you choose not to
provide the following information. USCIS displays this
information on our website for people who want to find a civil
surgeon.
6. Email Address (For use by the public)
Part 2. Clinical Office Locations
7.
Website Address (URL)
Fees for Medical Examination
8.
Acceptable Means of Payment
9.
Languages Spoken
11.
Part 3. Information About Your Status in the
United States
1.
I am a U.S. citizen or national
(Attach proof that you
are a U.S. citizen or national, such as a copy of a U.S.
passport, birth certificate, or Certificate of
Naturalization.)
2.
I am a Lawful Permanent Resident. (Attach a copy
of your valid Form I-551, Permanent Resident Card.
If you are currently seeking to renew or replace your
Form I-551, attach evidence showing that you are
doing so.)
You must be authorized to work in the United States to be
eligible for civil surgeon designation. Select the box that
accurately states how you are authorized to work in the United
States.
Other
14.
You must provide the following information. Failure to provide
this information may result in the denial of your application.
Refer to Part 2., Section B for more information about what
will be made publicly available.
Name of Clinic/Practice
1.
A. Required Information
Accepted Medical Insurance Plans
10.
Office Hours
12.
Handicap Accessibility
13.
Provide the following information about the locations where
you seek to perform immigration medical examinations. If you
seek to perform immigration medical exams in more than one
location, provide the details for each additional location in the
space provided in Part 9. Additional Information.
Page 3 of 7Form I-910 12/23/16 N
Dates of Attendance (mm/dd/yyyy)1.b.
From
To
1.c.
Degree
Part 4. Medical Licenses
Date Issued (mm/dd/yyyy)1.c.
Date Expires (mm/dd/yyyy)1.d.
1.b.
Medical License Number
1.a.
State
Medical License 1
U.S. Territory
OR
You must be licensed to practice medicine in the state or
territory in which you seek to perform immigration medical
examinations to be eligible for civil surgeon designation.
Attach a copy of each medical license listed below. If you
need extra space to complete this section, use the space
provided in Part 9. Additional Information.
Medical License 2
Date Issued (mm/dd/yyyy)2.c.
Date Expires (mm/dd/yyyy)2.d.
2.b.
Medical License Number
2.a.
State
OR
U.S. Territory
5. I have been granted another status under U.S.
immigration law that allows me to work and to
practice medicine in the United States:
Part 3. Information About Your Status in the
United States (continued)
1.a. School Name
School 1
Part 5. Medical Degrees
You must possess a medical degree as a Doctor of Medicine
(M.D.) or Doctor of Osteopathy (D.O.) to be eligible for civil
surgeon designation. Attach a copy of each medical degree
listed below. If you need extra space to complete this section,
use the space provided in Part 9. Additional Information.
Passport Number
4.d. Travel Document Number
4.c.
Current Nonimmigrant Status
4.g.
(mm/dd/yyyy)
Expiration Date for Passport or Travel Document4.f.
4.e.
Country of Issuance for Passport or Travel Document
Date of Last Arrival in the U.S. (mm/dd/yyyy)4.a.
4.b. Form I-94 Arrival-Departure Record Number (if any)
►
I am currently present in the United States as a
nonimmigrant (Attach a copy of your Form I-94
Arrival-Departure Record, a copy of your passport or
travel document, and any documents related to your
nonimmigrant status, such as a copy of the petition,
petition approval, and change or extension of status
application. Also attach a copy of your valid,
unexpired Employment Authorization Document as
proof of your authorization to work in the United
States, if required.)
3.
Page 4 of 7Form I-910 12/23/16 N
Part 7. Applicant's Statement, Contact
Information, Certification, and Signature
NOTE: If applicable, select the box for Item Number 1.
NOTE: Read the Penalties section of the Form I-910
Instructions before completing this part. You must file Form
I-910 while in the United States.
Applicant's Statement
1. At my request, the preparer named in Part 8.,
prepared this application for me based only upon
information I provided or authorized.
,
Part 6. Professional Experience
Employer 2
2.b.
2.a.
Employer's Name
Dates of Employment
(mm/dd/yyyy)
From To
Employer 1
Dates of Employment (mm/dd/yyyy)1.b.
1.a.
Employer's Name
From
To
Employer's Daytime Telephone Number1.h.
1.e. City or Town
1.f. State 1.g. ZIP Code
Street Number
and Name
1.c.
1.d. Apt. Flr.Ste.
Employer's Daytime Telephone Number2.h.
2.e. City or Town
2.f. State 2.g. ZIP Code
Street Number
and Name
2.c.
2.d. Apt. Flr.Ste.
NOTE: In calculating whether you meet the requirement of
four years' practice as a physician, DO NOT count your
post graduate medical training in an internship or residency
program. You can, however, count the time you practiced
medicine on the basis of a post-residency fellowship.
You must establish that you have practiced medicine as a
physician (M.D. or D.O.) for at least four years to be eligible for
designation.
Applicant's Contact Information
Applicant's Daytime Telephone Number2.
Applicant's Email Address (if any)4.
Applicant's Mobile Telephone Number (if any)3.
School 2
2.c.
Degree
2.a.
School Name
Dates of Attendance (mm/dd/yyyy)2.b.
From
To
Part 5. Medical Degrees (continued)
Submit evidence to establish your professional experience,
such as evaluations, certificates of completion, business tax
returns and business license (for self-employed physicians),
or letters of employment verification. If you need extra space
to complete this section, use the space provided in Part 9.
Additional Information.
By signing this application, I further agree to comply fully with
the regulations at 8 CFR 232. I understand that USCIS reserves
the right to revoke civil surgeon designation in certain
circumstances.
By signing this application, I accept civil surgeon designation if
my request for designation is granted. Once designated as a
civil surgeon, I agree that I will perform the medical
examinations according to the regulations published by Health
and Human Services (HHS) at 42 CFR 34 and the Technical
Instructions for Civil Surgeons by the Centers for Disease
Control and Prevention (CDC), including periodic updates.
Applicant's Certification
Page 5 of 7Form I-910 12/23/16 N
I am not an attorney or accredited representative but
have prepared this application on behalf of the
applicant and with the applicant's consent.
8.a.
8.b.
preparation of this application.
I am an attorney or accredited representative and my
representation of the applicant in this case
extends
does not extend beyond the
Preparer's Statement
NOTE: If you are an attorney or accredited
representative, you may be obliged to submit a
completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited
Representative, with this application.
Preparer's Contact Information
4. Preparer's Daytime Telephone Number
6. Preparer's Email Address (if any)
5. Preparer's Fax Number
Select this box if the preparer may act as a secondary
point of contact for you. USCIS will contact this
preparer if you cannot be reached using the
information in Part 2.
7.
Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Attorney or Representative Only: May USCIS contact you
by fax or email if we need to issue a Request for Evidence
(RFE)?
1.a.
Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)
1.b.
Provide the following information about the preparer.
Preparer's Business or Organization Name (if any)2.
Yes No
Preparer's Full Name
Preparer's Mailing Address
3.h.
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f.
Province
Street Number
and Name
3.a.
Country
3.b. Apt. Flr.Ste.
3.g. Postal Code
Part 7. Applicant's Statement, Contact
Information, Certification, and Signature
(continued)
I certify, under penalty of perjury, that I provided or authorized
all of the information in my application, I understand all of the
information contained in, and submitted with, my application,
and that all of this information is complete, true, and correct.
I further authorize release of information contained in this
application, in supporting documents, and in my USCIS records
to other entities and persons where necessary for the
administration and enforcement of U.S. immigration laws.
I authorize the release of any information from my records
which USCIS deems necessary in order to determine my
eligibility for designation as a civil surgeon.
Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
that USCIS may require that I submit original documents to
USCIS at a later date. Furthermore, I authorize the release of
any information from any of my records that USCIS may need
to determine my eligibility for the designation that I seek.
Applicant's Signature
Date of Signature (mm/dd/yyyy)5.b.
Applicant's Signature5.a.
NOTE TO ALL APPLICANTS: If you do not completely fill
out this application or fail to submit required documents listed
in the Instructions, USCIS may deny your application.
Page 6 of 7Form I-910 12/23/16 N
Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
(continued)
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
prepared this application at the request of the applicant. The
applicant then reviewed this completed application and
informed me that he or she understands all of the information
contained in, and submitted with, his or her application,
including the Applicant's Certification, and that all of this
information is complete, true, and correct. I completed this
application based only on information that the applicant
provided to me or authorized me to obtain or use.
9.a. Preparer's Signature
9.b. Date of Signature (mm/dd/yyyy)
Preparer's Signature
Page 7 of 7Form I-910 12/23/16 N
4.a.
Page Number
4.b. Part Number 4.c. Item Number
4.d.
6.a.
Page Number
6.b.
Part Number
6.c.
Item Number
6.d.
7.a.
Page Number
7.b.
Part Number
7.c.
Item Number
7.d.
5.a.
Page Number
5.b.
Part Number
5.c.
Item Number
5.d.
3.a.
Page Number
3.b. Part Number
3.c. Item Number
3.d.
Part 9. Additional Information
If you need extra space to provide any additional information
within this application, 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 application or attach a separate
sheet of paper. Include your name and CSID Number (if any) 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.
Your Full Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
CSID Number (if any)2.
