USCIS Form I-910 "Application for Civil Surgeon Designation"

What Is USCIS Form I-910?

This is a legal form that was released by the U.S. Department of Homeland Security - Citizenship and Immigration Services on May 29, 2018 and used country-wide. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on May 29, 2018;
  • The latest available edition released by the U.S. Department of Homeland Security - Citizenship and Immigration Services;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of USCIS Form I-910 by clicking the link below or browse more documents and templates provided by the U.S. Department of Homeland Security - Citizenship and Immigration Services.

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Download USCIS Form I-910 "Application for Civil Surgeon Designation"

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Application for Civil Surgeon Designation
USCIS
Form I-910
Department of Homeland Security
OMB No. 1615-0114
U.S. Citizenship and Immigration Services
Expires 05/31/2020
Initial Receipt
Barcode
Action Block
For
USCIS
Use
Resubmitted
Only
Received
Remarks
Sent
CSID Number
To be completed by an
Select this box if Form
Attorney State Bar
Attorney or Accredited Representative
G-28 is attached to
Number (if applicable)
USCIS Online Account Number (if any)
attorney or accredited
represent the applicant.
representative (if any).
START HERE - Type or print in black ink.
3.b.
Date of Voluntary Termination (mm/dd/yyyy)
Part 1. Information About You (The Applicant)
1.a. Have you ever been designated as a civil surgeon?
NOTE: If you answered "Yes" to Item Number 2.a. or Item
Yes
No
Number 3.a., above, include a typed or printed explanation of
the circumstances surrounding the revocation or voluntary
If you answered "Yes" to Item Number 1.a., provide the
termination in Part 9. Additional Information.
following information.
1.b.
Period of Designation (mm/dd/yyyy)
Your Full Name
From
To
4.a. Family Name
(Last Name)
U.S. Citizenship and Immigration Services (USCIS)
1.c.
Office That Granted the Designation
4.b. Given Name
(First Name)
4.c. Middle Name
1.d.
Civil Surgeon Identification Number (CSID) (if known)
Other Names Used
2.a. Has USCIS ever revoked your designation?
List all other names you have ever used, including aliases,
Yes
No
maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 9.
If you answered "Yes" to Item Number 2.a., provide the
Additional Information.
following information.
5.a. Family Name
2.b.
Date of Revocation (mm/dd/yyyy)
(Last Name)
5.b. Given Name
3.a. Have you ever voluntarily terminated your designation?
(First Name)
Yes
No
5.c.
Middle Name
If you answered "Yes" to Item Number 3.a., provide the
following information.
Other Information
6.
Date of Birth (mm/dd/yyyy)
7.
Gender
Male
Female
Form I-910 05/29/18
Page 1 of 6
Application for Civil Surgeon Designation
USCIS
Form I-910
Department of Homeland Security
OMB No. 1615-0114
U.S. Citizenship and Immigration Services
Expires 05/31/2020
Initial Receipt
Barcode
Action Block
For
USCIS
Use
Resubmitted
Only
Received
Remarks
Sent
CSID Number
To be completed by an
Select this box if Form
Attorney State Bar
Attorney or Accredited Representative
G-28 is attached to
Number (if applicable)
USCIS Online Account Number (if any)
attorney or accredited
represent the applicant.
representative (if any).
START HERE - Type or print in black ink.
3.b.
Date of Voluntary Termination (mm/dd/yyyy)
Part 1. Information About You (The Applicant)
1.a. Have you ever been designated as a civil surgeon?
NOTE: If you answered "Yes" to Item Number 2.a. or Item
Yes
No
Number 3.a., above, include a typed or printed explanation of
the circumstances surrounding the revocation or voluntary
If you answered "Yes" to Item Number 1.a., provide the
termination in Part 9. Additional Information.
following information.
1.b.
Period of Designation (mm/dd/yyyy)
Your Full Name
From
To
4.a. Family Name
(Last Name)
U.S. Citizenship and Immigration Services (USCIS)
1.c.
Office That Granted the Designation
4.b. Given Name
(First Name)
4.c. Middle Name
1.d.
Civil Surgeon Identification Number (CSID) (if known)
Other Names Used
2.a. Has USCIS ever revoked your designation?
List all other names you have ever used, including aliases,
Yes
No
maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 9.
If you answered "Yes" to Item Number 2.a., provide the
Additional Information.
following information.
5.a. Family Name
2.b.
Date of Revocation (mm/dd/yyyy)
(Last Name)
5.b. Given Name
3.a. Have you ever voluntarily terminated your designation?
(First Name)
Yes
No
5.c.
Middle Name
If you answered "Yes" to Item Number 3.a., provide the
following information.
Other Information
6.
Date of Birth (mm/dd/yyyy)
7.
Gender
Male
Female
Form I-910 05/29/18
Page 1 of 6
Additional Office Information
Part 1. Information About You (The Applicant)
(continued)
Your application will not be affected if you choose not to provide
the following information. USCIS displays this information on
8.
USCIS Online Account Number (if any)
our website for people who want to find a civil surgeon.
6.
Email Address (For Use By The Public)
9.
Alien Registration Number (A-Number, if any)
A-
7.
Website Address (URL)
Part 2. Clinical Office Locations
8.
Fees for Medical Examination
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
9.
Acceptable Means of Payment
location, provide the details for each additional location in the
space provided in Part 9. Additional Information.
10.
Accepted Medical Insurance Plans
Name and Physical Address of the Clinic/Practice
11.
Languages Spoken
You must provide the following information. Failure to provide
this information may result in the denial of your application.
See the Additional Office Information section below for more
information about what will be made publicly available.
1.
Name of Clinic/Practice
12.
Office Hours
2.a.
Street Number
13.
Handicap Accessibility
and Name
2.b.
Apt.
Ste.
Flr.
14.
Other
2.c.
City or Town
2.d.
State
2.e. ZIP Code
(USPS ZIP Code Lookup)
3.
Telephone Number
Part 3. Information About Your Status in the
4.
Fax Number
United States
You must be authorized to work in the United States to be
5.
Email Address (For Use By USCIS)
eligible for civil surgeon designation. Select the box that
accurately states how you are authorized to work in the United
States. (Select only one box.)
NOTE: USCIS will use the contact information listed above
for all civil surgeon-related communication.
1.
I am a U.S. citizen or national. (Attach proof that you
UPDATE USCIS OF ANY CHANGES: Civil surgeons are
are a U.S. citizen or national, such as a copy of a U.S.
responsible for notifying USCIS in writing of any updates to the
passport, birth certificate, or Certificate of
contact information provided in this application within 15 days
Naturalization.)
of the change. Visit the USCIS website at
www.uscis.gov/I-910
2.
I am a Lawful Permanent Resident. (Attach a copy
for information on how to submit a change.
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.)
Form I-910 05/29/18
Page 2 of 6
1.c.
Part 3. Information About Your Status in the
Date Issued (mm/dd/yyyy)
United States (continued)
1.d.
Date Expires (mm/dd/yyyy)
3.a.
I am currently present in the United States as a
nonimmigrant. (Attach a copy of your Form I-94
Medical License 2
Arrival-Departure Record, a copy of your passport
or travel document, and any documents related to
2.a. State
OR
your nonimmigrant status, such as a copy of the
petition, petition approval, and change or extension
U.S. Territory
of status application. Also attach a copy of your
2.b. Medical License Number
valid, unexpired Employment Authorization
Document as proof of your authorization to work in
the United States, if required.)
2.c.
Date Issued (mm/dd/yyyy)
3.b.
Date of Last Arrival in the U.S. (mm/dd/yyyy)
2.d.
Date Expires (mm/dd/yyyy)
3.c. Form I-94 Arrival-Departure Record Number (if any)
Part 5. Medical Degrees
3.d.
Passport Number
You must possess a medical degree as a Doctor of Medicine
(M.D.) or Doctor of Osteopathy (D.O.) to be eligible for civil
3.e. Travel Document Number
surgeon designation. Attach a copy of each medical degree
listed below. If you need extra space to complete this section,
3.f.
Country of Issuance for Passport or Travel Document
use the space provided in Part 9. Additional Information.
School 1
3.g.
Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
1.a. School Name
3.h.
Current Nonimmigrant Status
1.b.
Dates of Attendance (mm/dd/yyyy)
From
To
4.
I have an Employment Authorization Document
(EAD) granted by USCIS that authorizes me to
1.c. Degree
work in the United States. (Attach a copy of your
valid, unexpired EAD as proof of your authorization
to work in the United States.)
School 2
Part 4. Medical Licenses
2.a. School Name
You must be licensed to practice medicine in the state or U.S.
territory in which you seek to perform immigration medical
2.b.
Dates of Attendance (mm/dd/yyyy)
examinations to be eligible for civil surgeon designation. Attach
From
To
a copy of each medical license listed below. If you need extra
space to complete this section, use the space provided in Part 9.
2.c. Degree
Additional Information.
Medical License 1
1.a. State
OR
U.S. Territory
1.b. Medical License Number
Form I-910 05/29/18
Page 3 of 6
Part 6. Professional Experience
Part 7. Applicant's Statement, Contact
Information, Declaration, Certification, and
You must establish that you have practiced medicine as a
Signature
physician (M.D. or D.O.) for at least four years to be eligible for
designation.
NOTE: Read the Penalties section of the Form I-910
NOTE: In calculating whether you meet the requirement of
Instructions before completing this section. You must file Form
four years of practice as a physician, DO NOT count your post
I-910 while in the United States.
graduate medical training in an internship or residency program.
You can, however, count the time you practiced medicine on
Applicant's Statement
the basis of a post-residency fellowship.
NOTE: If applicable, select the box for Item Number 1.
Submit evidence to establish your professional experience, such
as evaluations, certificates of completion, business tax returns
1.
At my request, the preparer named in Part 8.,
and business license (for self-employed physicians), or letters of
,
employment verification. If you need extra space to complete
prepared this application for me based only upon
this section, use the space provided in Part 9. Additional
information I provided or authorized.
Information.
Applicant's Contact Information
Employer 1
2.
Applicant's Daytime Telephone Number
1.a. Employer's Name
3.
Applicant's Mobile Telephone Number (if any)
1.b.
Dates of Employment (mm/dd/yyyy)
From
To
4.
Applicant's Email Address (if any)
1.c.
Street Number
and Name
1.d.
Apt.
Ste.
Flr.
Applicant's Declaration and Certification
1.e. City or Town
By signing this application, I accept civil surgeon designation if
my request for designation is granted. Once designated as a
1.f.
1.g. ZIP Code
State
civil surgeon, I agree that I will perform the medical
examinations according to the regulations published by Health
1.h.
Employer's Daytime Telephone Number
and Human Services (HHS) at 42 CFR Part 34 and the
Technical Instructions for Civil Surgeons by the Centers for
Disease Control and Prevention (CDC).
Employer 2
By signing this application, I further agree to comply fully with
the regulations at 8 CFR Part 232. I understand that USCIS
2.a. Employer's Name
reserves the right to revoke civil surgeon designation in certain
circumstances.
2.b.
Dates of Employment (mm/dd/yyyy)
Copies of any documents I have submitted are exact photocopies
From
To
of unaltered, original documents, and I understand that USCIS
may require that I submit original documents to USCIS at a later
2.c.
Street Number
date. Furthermore, I authorize the release of any information
and Name
from any and all of my records that USCIS may need to
2.d.
Apt.
Ste.
Flr.
determine my eligibility for designation as a civil surgeon.
I furthermore authorize release of information contained in this
2.e. City or Town
application, in supporting documents, and in my USCIS records,
to other entities and persons where necessary for the
2.f.
State
2.g. ZIP Code
administration and enforcement of U.S. immigration law.
2.h.
Employer's Daytime Telephone Number
Form I-910 05/29/18
Page 4 of 6
Preparer's Contact Information
Part 7. Applicant's Statement, Contact
Information, Declaration, Certification, and
4.
Preparer's Daytime Telephone Number
Signature (continued)
I certify, under penalty of perjury, that all of the information in
5.
Preparer's Mobile Telephone Number (if any)
my application and any document submitted with it were
provided or authorized by me, that I reviewed and understand
all of the information contained in, and submitted with, my
6.
Preparer's Email Address (if any)
application and that all of this information is complete, true,
and correct.
7.
Select this box if the preparer may act as a secondary
Applicant's Signature
point of contact for you. USCIS will contact this
preparer if you cannot be reached using the
5.a.
Applicant's Signature
information in Part 2.
Preparer's Statement
5.b.
Date of Signature (mm/dd/yyyy)
I am not an attorney or accredited representative but
8.a.
NOTE TO ALL APPLICANTS: If you do not completely fill
have prepared this application on behalf of the
out this application or fail to submit required documents listed
applicant and with the applicant's consent.
in the Instructions, USCIS may deny your application.
I am an attorney or accredited representative and my
8.b.
representation of the applicant in this case
Part 8. Contact Information, Declaration, and
extends
does not extend beyond the
Signature of the Person Preparing this
preparation of this application.
Application, if Other Than the Applicant
NOTE: If you are an attorney or accredited
representative, you may need to submit a completed
Provide the following information about the preparer.
Form G-28, Notice of Entry of Appearance as
Attorney or Accredited Representative, with this
Preparer's Full Name
application.
1.a. Preparer's Family Name (Last Name)
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
1.b.
Preparer's Given Name (First Name)
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
2.
Preparer's Business or Organization Name (if any)
contained in, and submitted with, his or her application,
including the Applicant's Declaration and Certification, and
that all of this information is complete, true, and correct. I
Preparer's Mailing Address
completed this application based only on information that the
applicant provided to me or authorized me to obtain or use.
3.a.
Street Number
and Name
Preparer's Signature
3.b.
Apt.
Ste.
Flr.
9.a. Preparer's Signature
3.c. City or Town
3.d. State
3.e. ZIP Code
9.b. Date of Signature (mm/dd/yyyy)
3.f.
Province
3.g. Postal Code
3.h.
Country
Form I-910 05/29/18
Page 5 of 6