Fillable Printable G 28
Fillable Printable G 28
G 28
Form G-28 05/05/16 Y Page 1 of 4
Part 1. Information About Attorney or
Accredited Representative
Name and Address of Attorney or Accredited
Representative
4.
Fax Number5.
6.
Mobile Telephone Number (if any)7.
E-Mail Address (if any)
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Middle Name
Daytime Telephone Number
Notice of Entry of Appearance
as Attorney or Accredited Representative
Department of Homeland Security
DHS
Form G-28
OMB No. 1615-0105
Expires 03/31/2018
1. USCIS ELIS Account Number (if any)
►
Street Number
and Name
3.a.
3.b. Apt. Flr.Ste.
3.c. City or Town
3.d. State 3.e. ZIP Code
Information About Applicant, Petitioner,
Requestor, or Respondent
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c. Middle Name
6. Name of Company or Organization (if applicable)
I enter my appearance as attorney or accredited representative at
the request of:
4.
Applicant
Select only one box:
Petitioner
Respondent (ICE, CBP)
2.a.
ICE
List the specific matter in which appearance is entered2.b.
3.a.
CBP
List the specific matter in which appearance is entered3.b.
1.a. USCIS
List the form numbers
1.b.
Part 2. Notice of Appearance as Attorney or
Accredited Representative
This appearance relates to immigration matters before
(Select only one box):
3.f. Province
3.g. Postal Code
3.h. Country
Requestor
Form G-28 05/05/16 Y Page 2 of 4
2.b. Name of Recognized Organization
2.c. Date accreditation expires
(mm/dd/yyyy) ►
Province
12.f.
Postal Code
12.g.
Country 12.h.
12.a. Street Number
and Name
12.c. City or Town
12.d.
State
12.e.
ZIP Code
12.b. Apt.
Flr.Ste.
NOTE: Provide the mailing address of the applicant, petitioner,
requestor, or respondent. Do not provide the business mailing
address of the attorney or accredited representative unless it
serves as the safe mailing address on the application, petition, or
request being filed with this Form G-28.
Mailing Address of Applicant, Petitioner,
Requestor, or Respondent
Part 2. Notice of Appearance as Attorney or
Accredited Representative (continued)
2.a. I am an accredited representative of the following
qualified nonprofit religious, charitable, social
service, or similar organization established in the
United States, so recognized by the Department of
Justice, Board of Immigration Appeals, in accordance
with 8 CFR 292.2. Provide the name of the
organization and the expiration date of accreditation.
1.d. I (choose one) am not am
subject to any order of any court or administrative agency
disbarring, suspending, enjoining, restraining, or otherwise
restricting me in the practice of law. If you are subject to
any orders, explain in the space below. (If you need
additional space, use Part 6.)
1.b.
Bar Number (if applicable)
Licensing Authority
10.
E-Mail Address (if any)
9.
Mobile Telephone Number (if any)
Information About Applicant, Petitioner,
Requestor, or Respondent (continued)
1.c. Name of Law Firm
11.
Daytime Telephone Number
Part 3. Eligibility Information for Attorney or
Accredited Representative
Select all applicable items.
1.a. I am an attorney eligible to practice law in, and a
member in good standing of, the bar of the highest
courts of the following states, possessions, territories,
commonwealths, or the District of Columbia. (If you
need additional space, use Part 6.)
8. Alien Registration Number (A-Number) or Receipt Number
7. USCIS ELIS Account Number (if any)
►
Form G-28 05/05/16 Y Page 3 of 4
I request that DHS send any secure identity document,
such as a Permanent Resident Card, Employment
Authorization Document, or Travel Document, that I am
approved to receive and authorized to possess, to the
U.S. business address of my attorney of record or
accredited representative as listed in this form or to a
designated military or diplomatic address for pickup in a
foreign country (if permitted). I consent to having my
secure identity document sent to my attorney of record
or accredited representative's U.S. business address and
understand that I may request, at any future date and
through written notice to DHS, that DHS send any
secure identity document to me directly.
2.b.
Part 5. Signature of Attorney or Accredited
Representative
I have read and understand the regulations and conditions
contained in 8 CFR 103.2 and 292 governing appearances and
representation before the Department of Homeland Security.
I declare under penalty of perjury under the laws of the United
States that the information I have provided on this form is true
and correct.
1. Signature of Attorney or Accredited Representative
2. Signature of Law Student or Law Graduate
3. Date of Signature (mm/dd/yyyy)►
I request DHS send any notice (including Form I-94)
on an application, petition, or request to the U.S.
business address of my attorney of record or
accredited representative as listed in this form. I
understand that I may change this election at any
future date through written notice to DHS.
2.a
Part 4. Applicant, Petitioner, Requestor, or
Respondent Consent to Representation, Contact
Information, and Signature
I have requested the representation of and consented to
being represented by the attorney or accredited
representative named in Part 1. of this form. According
to the Privacy Act of 1974 and DHS policy, I also consent
to the disclosure to the named attorney or accredited
representative of any record pertaining to me that appears
in any system of records of USCIS, ICE or CBP.
1.
Consent to Representation and Release of Information
3.a. Signature of Applicant, Petitioner, Requestor, or
Respondent
3.b. Date of Signature (mm/dd/yyyy)►
4.a.
4.b.
I am a law student or law graduate working under the
direct supervision of the attorney or accredited
representative of record on this form in accordance
with the requirements in 8 CFR 292.1(a)(2)(iv).
Name of Law Student or Law Graduate
If you do not want to receive original notices or secure
identity documents directly, but would rather have such
notices and documents sent to your attorney of record or
accredited representative, please select all applicable
boxes below:
3. I am associated with
the attorney or accredited representative of record
who previously filed Form G-28 in this case, and my
appearance as an attorney or accredited representative
is at his or her request.
,
NOTE: If you select this item, also complete Item
Numbers 1.a. - 1.b. or Item Numbers 2.a. - 2.c. in
Part 3. (whichever is appropriate).
Part 3. Eligibility Information for Attorney or
Accredited Representative (continued)
When you (the applicant, petitioner, requestor, or
respondent) are represented, DHS will send notices to both
you and your attorney or accredited representative either
through mail or electronic delivery.
DHS will also send the Form I-94, Arrival Departure
Record, to you unless you select Item Number 2.a. in
Part 4. All secure identity documents and Travel
Documents will be sent to you (the applicant, petitioner,
requestor, or respondent) at your U.S. mailing address
unless you ask us to send your secure identity documents
to your attorney of record or accredited representative.
Form G-28 05/05/16 Y Page 4 of 4
Part 6. Additional Information
Use the space provided below to provide additional information
pertaining to Part 3., Item Numbers 1.a. - 1.d. or to provide
your U.S. business address for purposes of receiving secure
identity documents for your client (if your client has consented
to your receipt of such documents under Part 4.)
