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Get Example Completed Form N265

Or print in black ink Part 1. Information about you. Family Name Given Name For USCIS Use Only Receipt Returned Middle Name Address - In care of: Street Number and Name Apt. Number City or Town Resubmitted State or Province Zip or Postal Code Country Date of Birth (mm/dd/yyyy) Country of Birth Certificate Number A-Number Telephone Number (with area/country codes) E-Mail Address (if any) Reloc Sent Reloc Rec'd Part 2. Type of application 1. I hereby apply for: (check one) a. b.

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