INSTRUCTIONS Form I-910, Application for Civil Surgeon

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TABLE OF CHANGES – INSTRUCTIONSForm I-910, Application for Civil Surgeon Designation

OMB Number: 1615-011404/20/2020

Reason for Revision:

Legend for Proposed Text:• Black font = Current text• Red font = Changes

Expires 05/31/2020Edition Date 05/29/2018

Current Page Numberand Section

Current Text Proposed Text

Page 1,What Is the Purpose ofForm I-910?

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What Is the Purpose of Form I-910?

Form I-910, Application for Civil SurgeonDesignation, is used by physicians seekingdesignation as a civil surgeon.

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Page 1,What Is a Civil Surgeon?

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What Is a Civil Surgeon?

By law, a civil surgeon is a physiciandesignated by U.S. Citizenship andImmigration Services (USCIS) to conductimmigration medical examinations forindividuals applying for an immigrationbenefit in the United States.

Unless you are a medical officer of U.S.Public Health Service (PHS), you musthave civil surgeon designation if you wishto conduct immigration medicalexaminations in the United States. If youare not a designated USCIS civil surgeon(or a PHS medical officer), you are notauthorized to conduct medicalexaminations for immigration benefitapplications in the United States orcomplete Form I-693, Report of MedicalExamination and Vaccination Record.

Civil surgeon designation does notauthorize you to conduct immigration

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Unless you are a medical officer of the U.S.Public Health Service (USPHS), you musthave civil surgeon designation if you wishto conduct immigration medicalexaminations for immigration benefitapplicants in the United States. If you arenot a USCIS-designated civil surgeon (or aUSPHS medical officer), you are notauthorized to conduct immigration medicalexaminations for immigration benefitapplications in the United States or tocomplete Form I-693, Report of MedicalExamination and Vaccination Record.

Civil surgeon designation does notauthorize you to conduct immigration

AILA Doc. No. 20050434. (Posted 5/4/20)

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medical examinations for individualsseeking immigration benefits abroadthrough the visa issuance process of U.S.Department of State (DOS). Thoseimmigration medical examinations areconducted by DOS-designated panelphysicians overseas. For more information,visit the DOS website attravel.state.gov/content/travel/en/us-visas/immigrate/the-immigrant-visa-process/interview/interview-prepare/medical-examination.html.

NOTE: Physicians performing medicalexaminations not related to immigrationbenefits, including medical examinationsfor immigration detainees or U.S.Immigration and Customs Enforcement(ICE), U.S. Customs and Border Protection(CBP), and other government entities (forexample, PHS physicians), are not requiredto have civil surgeon designation.

medical examinations for individualsseeking immigration benefits abroadthrough the visa issuance process of theU.S. Department of State (DOS). OnlyDOS-designated panel physicians overseasmay conduct such examinations. For moreinformation, visit the DOS website attravel.state.gov/content/travel/en/us-visas/immigrate/the-immigrant-visa-process/interview/interview-prepare/medical-examination.html.

NOTE: Civil surgeon designation is notrequired for physicians who performmedical examinations, unrelated to animmigration benefit, for detainees withinthe custody of U.S. Immigration andCustoms Enforcement (ICE), U.S. Customsand Border Protection (CBP), and othergovernment entities.

Page 1,Who Should Use Form I-910?

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Who Should Use Form I-910?

Use Form I-910 if you are a physicianseeking civil surgeon designation toperform immigration medical examinationsin the United States and complete Form I-693, but you are not currently designatedas a civil surgeon.

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NOTE: Military and public healthdepartment physicians who qualify forblanket civil surgeon designation by USCISare not required to apply for civil surgeon

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Who Should Use Form I-910?

Use Form I-910 if you are a physicianseeking civil surgeon designation toperform immigration medical examinationsfor immigration benefit applications in theUnited States and complete Form I-693.

Do not use Form I-910 if you are a militaryor public health department physician whoqualifies for blanket civil surgeondesignation by USCIS. Public healthdepartment physicians may only use theblanket civil surgeon designation tocomplete the vaccination assessments forrefugees, not asylees, seeking adjustment ofstatus. Military physicians who qualify forblanket civil surgeon designation maycomplete all parts of a requiredimmigration medical examination formembers and veterans of the U.S. ArmedForces and certain eligible dependents ifthe military physician meets certainconditions. For more information, pleasevisit www.uscis.gov/civilsurgeons.

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designation on Form I-910. Forinformation on blanket civil surgeondesignation, visitwww.uscis.gov/civilsurgeons.

Page 1,What ProfessionalQualifications AreRequired for Civil SurgeonDesignation?

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What Professional Qualifications AreRequired for Civil SurgeonDesignation?

In order for USCIS to designate you as acivil surgeon, you must:

1. Have an unrestricted license as a doctorof medicine (M.D.) or doctor of osteopathy(D.O.) in the U.S state or U.S. territory inwhich you seek to perform immigrationmedical examinations;

2. Have at least four years of professionalexperience as a physician; and

3. Have authorization to work in theUnited States.

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For USCIS to designate you as a civilsurgeon, you must:

1. Have an active and unrestricted licenseas a doctor of medicine (M.D.) or doctor ofosteopathy (D.O.) in the U.S. state or U.S.territory where you seek to performimmigration medical examinations;

2. Have at least four years of professionalexperience as a physician in the U.S.; and

3. Have authorization to work in the UnitedStates.

Page 2,Are There OtherRequirements for CivilSurgeon Designation?

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Are There Other Requirements for CivilSurgeon Designation?

In addition to meeting the professionalqualifications, you must:

1. Apply for civil surgeon designationusing Form I-910;

2. Submit the completed Form I-910 withthe correct filing fee; and

3. Have active medical practices at thelocations where you are requesting toperform immigration medicalexaminations. USCIS will not grant yourcivil surgeon designation for locationswhere you intend to practice only in thefuture or where you no longer practice.

NOTE: Civil surgeon designation is at thediscretion of USCIS. Although you maymeet the specified, professionalqualifications and other requirements listedon Form I-910, USCIS cannot guarantee

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NOTE: Civil surgeon designation is at thediscretion of USCIS. Although you maymeet the specified professionalqualifications and other requirements listedon Form I-910, USCIS cannot guarantee


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you will receive designation as a civilsurgeon.

you will receive designation as a civilsurgeon.

Page 2-3,What Are theResponsibilities of a CivilSurgeon?

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What Are the Responsibilities of a CivilSurgeon?

If USCIS designates you as a civil surgeon,you must comply with the followingrequirements:

1. You are responsible for truthfully andaccurately reporting the results of anapplicant’s immigration medicalexamination and all laboratory reports onForm I-693, where indicated, and forsigning the civil surgeon’s certification onForm I-693.

You must take reasonable steps to ensurethe person appearing for the immigrationmedical examination is the same personapplying for the requested immigrationbenefit. Generally, applicants must presenta valid, government-issued photoidentification (for example, a valid,unexpired passport or driver’s license) atthe time of their immigration medicalexaminations, and you must annotate thetype of identification presented andidentification number in Part 1. of Form I-693, if applicable. The law imposes severepenalties for knowingly and willfullyfalsifying or concealing a material fact orusing any false documents in connectionwith immigration medical examinations.

You should also ensure the applicant’sname and Alien Registration Number (A-Number) (if any) are at the top of each pageof Form I-693 and match the informationprovided in Part 1. of Form I-693.

2. Follow Department of Health andHuman Services (HHS) regulations andCenters for Disease Control and Prevention(CDC) guidelines. USCIS designates civilsurgeons with the understanding you willperform the immigration medicalexamination according to HHS regulationsfound at 42 CFR part 34. These regulations

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What Are the Responsibilities of a CivilSurgeon?

If USCIS designates you as a civil surgeon,you must comply with the followingrequirements when performing civilsurgeon duties:

1. Truthfully and accurately report theresults of an applicant’s immigrationmedical examination and all laboratoryreports on Form I-693, where indicated,and sign the civil surgeon’s certification onForm I-693.

Take reasonable steps to ensure the personappearing for the immigration medicalexamination, including any laboratory test,vaccinations, or x-rays, is the same personapplying for the requested immigrationbenefit. Generally, applicants must presenta valid government-issued photoidentification (for example, a validunexpired passport or driver’s license) atthe time of their immigration medicalexamination, and you must annotate thetype of identification presented andidentification number in Part 5. of Form I-693. The law imposes severe penalties forknowingly and willfully falsifying orconcealing a material fact or using any falsedocuments in connection with immigrationmedical examinations.

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2. Follow Department of Health andHuman Services (HHS) regulations andCenters for Disease Control and Prevention(CDC) guidelines. Civil surgeons mustperform the immigration medicalexamination according to HHS regulationsfound at 42 CFR part 34. These regulationsinclude the specific guidelines found in the


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include the specific guidelines found in theTechnical Instructions for the MedicalExamination of Aliens in the United States(Technical Instructions), published by CDCin Atlanta, Georgia. Civil surgeons shouldaddress any questions about the TechnicalInstructions directly to CDC. USCIScannot answer medical questions involvingthe Technical Instructions. The TechnicalInstructions, including periodic updatesposted by CDC, are available on the CDCwebsite atwww.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html.

3. Make referrals and file case reports, asrequired. The CDC’s TechnicalInstructions require you to:

A. Refer the applicant to the local healthdepartment if the chest x-ray suggeststuberculosis (TB) or if other health-relatedcircumstances are present, as specified inthe CDC’s Technical Instructions;

B. Ensure testing and therapy are given fordiagnoses of communicable diseases ofpublic health significance, as outlined inthe CDC’s Technical Instructions; and

C. File a case report with the appropriatepublic health authorities if required by locallaws or regulations. You must also advisethe applicant you are filing a case report.

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4. Notify USCIS of any changes relevantto your designation as a civil surgeon. Youare responsible for notifying USCIS in theevent that:

A. You cease to practice medicine;

B. You cease to perform immigrationmedical examinations in the U.S. state orU.S. territory or at the locations associatedwith your civil surgeon designation; or

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CDC publication “Technical Instructionsfor Civil Surgeons” (TechnicalInstructions). Civil surgeons should addressany questions about the TechnicalInstructions directly to CDC. USCIS cannotanswer medical questions involving theTechnical Instructions. The TechnicalInstructions, including periodic updatesposted by CDC, are available on the CDCwebsite atwww.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html.

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A. Refer the applicant to the local healthdepartment if the chest x-ray suggeststuberculosis (TB) or if any other health-related circumstances are present, asspecified in the CDC’s TechnicalInstructions;

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C. File a case report with the appropriatepublic health authorities if required by locallaws or regulations. You must also advisethe applicant that you are filing a casereport.

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C. Your medical license is restricted and/or


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C. Your contact information changes (forexample, name of office, address, telephonenumber, fax number, or email address).

NOTE: You should notify USCIS within15 days of the change. See the When andHow Do I Update My Civil SurgeonInformation section of these Instructionsfor more information.

you are subject to any disciplinary action;or

D. Your contact information changes (forexample, name of office, address, telephonenumber, fax number, or email address).

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Page 3,Can USCIS Revoke CivilSurgeon Designation?

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Can USCIS Revoke Civil SurgeonDesignation?

USCIS may revoke a civil surgeondesignation. Reasons for revocationinclude, but are not limited to:

1. Failure to continue meeting theprofessional qualifications required for civilsurgeon designation;

2. Failure to meet the responsibilities of acivil surgeon, including failure to followthe CDC’s Technical Instructions;

3. Engaging in immigration fraud; or

4. Engaging in any activity that poses a riskto public health or safety.

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Can USCIS Revoke Civil SurgeonDesignation?

USCIS may revoke a civil surgeon’sdesignation at any time. Reasons forrevocation include, but are not limited to,your:

1. Failure to continue to meet theprofessional qualifications required for civilsurgeon designation;

2. Failure to meet the responsibilities of acivil surgeon, including failure to followthe CDC’s Technical Instructions and FormI-693 Instructions;

3. Engaging in immigration fraud,including providing false information inany materials provided in the course ofimmigration medical examinations; or

4. Engaging in any activity that poses a riskto public health or safety.

Page 3-4,General Instructions

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General Instructions

USCIS provides forms free of chargethrough the USCIS website. In order toview, print, or fill out our forms, youshould use the latest version of AdobeReader, which you can download for free athttp://get.adobe.com/reader/. If you do nothave internet access, you may call theUSCIS National Customer Service Centerat 1-800-375-5283 and ask that we mail aform to you. For TTY (deaf or hard ofhearing) call: 1-800-767-1833.

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General Instructions

USCIS provides forms free of chargethrough the USCIS website. To view,print, or fill out our forms, you should usethe latest version of Adobe Reader, whichyou can download for free athttp://get.adobe.com/reader/. If you donot have internet access, you may call theUSCIS Contact Center at 1-800-375-5283and ask that we mail a form to you. TheUSCIS Contact Center providesinformation in English and Spanish. For


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Signature. Each application must beproperly signed and filed. For allsignatures on this application, USCIS willnot accept a stamped or typewritten namein place of a signature.

Validity of Signatures. USCIS willconsider a photocopied, faxed, or scannedcopy of the original, handwritten signaturevalid for filing purposes. The photocopy,fax, or scan must be of the originaldocument containing the handwritten, inksignature.

Filing Fee. Each application must beaccompanied by the appropriate filingfee. (See the What Is the Filing Feesection of these Instructions.)

Evidence. At the time of filing, you mustsubmit all evidence and supportingdocuments listed in the SpecificInstructions section of these Instructions.

Copies. You should submit legiblephotocopies of documents requested, unlessthe Instructions specifically state that youmust submit an original document. USCISmay request an original document at thetime of filing or at any time duringprocessing of your application. If USCISrequests an original document from you, itwill be returned to you after USCISdetermines it no longer needs youroriginal.

NOTE: If you submit original documentswhen not required or requested by USCIS,your original documents may beimmediately destroyed after we receivethem.

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TTY (deaf or hard of hearing) call: 1-800-767-1833.

Signature. Each application must beproperly signed and filed. For allsignatures on this application, USCIS willnot accept a stamped or typewritten namein place of a signature. If the request is notsigned or if the requisite signature on therequest is not valid, USCIS will reject therequest. See 8 CFR 103.2(a)(7)(ii)(A). IfUSCIS accepts a request for adjudicationand determines that it has a deficientsignature, USCIS will deny the request.

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Copies. You should submit legiblephotocopies of documents requested, unlessthe Instructions specifically state that youmust submit an original document. USCISmay request an original document at thetime of filing or at any time duringprocessing of an application or petition. IfUSCIS requests an original document fromyou, it will be returned to you after USCISdetermines it no longer needs youroriginal.

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Translations. If you submit a documentwith information in a foreign language, youmust also submit a full Englishtranslation. The translator must sign acertification that the English languagetranslation is complete and accurate, andthat he or she is competent to translate fromthe foreign language into English. Thecertification must include the translator’ssignature. Department of HomelandSecurity (DHS) recommends thecertification contain the translator’s printedname, the signature date, and thetranslator’s contact information.

How To Fill Out Form I-910

1. Type or print legibly in black ink.

2. If you need extra space to complete anyitem within this application, use the spaceprovided in Part 9. AdditionalInformation or attach a separate sheet ofpaper. Type or print your name and CivilSurgeon Identification (CSID) Number (ifany) at the top of each sheet; indicate thePage Number, Part Number, and ItemNumber to which your answer refers; andsign and date each sheet.

3. Answer all questions fully andaccurately. If a question does not apply toyou (for example, if you have never beenmarried and the question asks, “Provide thename of your current spouse”), type or print“N/A” unless otherwise directed. If youranswer to a question which requires anumeric response is zero or none (forexample, “How many children do youhave” or “How many times have youdeparted the United States”), type or print“None” unless otherwise directed.

Translations. If you submit a documentwith information in a foreign language, youmust also submit a full Englishtranslation. The translator must sign acertification that the English languagetranslation is complete and accurate, andthat he or she is competent to translate fromthe foreign language into English. Thecertification must also include thetranslator’s signature, printed name, thesignature date, and the translator’s contactinformation.

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2. If you need extra space to complete anyitem within this application, use the spaceprovided in Part 10. AdditionalInformation or attach a separate sheet ofpaper. Type or print your name and CivilSurgeon Identification (CSID) Number (ifany) at the top of each sheet; indicate thePage Number, Part Number, and ItemNumber to which your answer refers; andsign and date each sheet.

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Page 4-7,Specific Instructions

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Specific Instructions

NOTE: You must submit all evidencerequested in these Instructions with yourapplication. If you fail to submit requiredevidence, USCIS may reject or deny yourapplication for failure to submit requestedevidence or supporting documents in

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accordance with 8 CFR 103.2(b)(1) andthese Instructions.

Part 1. Information About You (TheApplicant)

NOTE: Complete Item Numbers 1.a. -3.b. only if you were previously designatedas a civil surgeon.

Item Numbers 1.a. - 1.d. GeneralInformation About Previous CivilSurgeon Designation. If you werepreviously designated as a civil surgeon,select “Yes” and provide the period of priordesignation, the USCIS office that grantedthe designation, and the CSID Numberissued, if known.

Item Numbers 2.a. - 2.b. Revocation. IfUSCIS revoked your previous civil surgeondesignation, select “Yes” and provide thedate of revocation. Attach the revocationletter you received from USCIS. Alsoexplain the circumstances surrounding therevocation in a separate sheet of paperattached to your Form I-910 or in Part 9.Additional Information. Please note thatUSCIS may deny your Form I-910 if thegrounds upon which your previousdesignation was revoked still exist.

Item Numbers 3.a. - 3.b. VoluntaryTermination. If you voluntarilyterminated your previous civil surgeondesignation, select “Yes” and provide thedate of voluntary termination. Also explainthe circumstances surrounding thevoluntary termination in a separate sheet ofpaper attached to your Form I-910 or inPart 9. Additional Information.

Item Numbers 4.a. - 4.c. Your FullName. Provide your full legal name asshown on your birth certificate or legalname change document in the spacesprovided.

Item Numbers 5.a. - 5.c. Other NamesUsed. Provide all other names you haveused since birth, including your maidenname, any nicknames, and any names thatappear in your documents. If you need

NOTE: Complete Item Numbers 1. - 7.only if you were previously designated as acivil surgeon.

Item Numbers 1. - 3. GeneralInformation About Previous CivilSurgeon Designation. If you werepreviously designated as a civil surgeon,select “Yes” and provide the period of priordesignation and the CSID Number issued,if known.

Item Numbers 4. - 5. Revocation. IfUSCIS revoked your previous civil surgeondesignation, select “Yes” and provide thedate of revocation. Attach the revocationletter you received from USCIS. Alsoexplain the circumstances surrounding therevocation in a separate sheet of paperattached to your Form I-910 or in Part 10.Additional Information. Please note thatUSCIS may deny your Form I-910 if thegrounds upon which your previousdesignation was revoked still exist.

Item Numbers 6. - 7. VoluntaryTermination. If you voluntarily terminatedyour previous civil surgeon designation,select “Yes” and provide the date ofvoluntary termination. Also explain thecircumstances surrounding the voluntarytermination in a separate sheet of paperattached to your Form I-910 or in Part 10.Additional Information.

Item Number 8. Your Full Name. Provideyour full legal name as shown on your birthcertificate or legal name change documentin the spaces provided.

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Item Number 9. Other Names Used.Provide all other names you have usedsince birth, including your maiden name,any nicknames, and any names that appearin your documents. If you need extra space,


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extra space, use Part 9. AdditionalInformation to provide other names used.

Item Number 6. Date of Birth. Provideyour date of birth in mm/dd/yyyy format inthe space provided. For example, type orprint October 5, 1967 as 10/05/1967.

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Item Number 7. Gender. Select the boxthat indicates whether you are male orfemale.

Item Number 8. USCIS Online AccountNumber (if any). If you have previouslyfiled an application or petition using theUSCIS online filing system (previouslycalled USCIS Electronic ImmigrationSystem (USCIS ELIS)), provide the USCISOnline Account Number you were issuedby the system. You can find your USCISOnline Account Number by logging in toyour account and going to the profilepage. If you previously filed certainapplications or petitions on a paper formthrough a USCIS Lockbox facility, youmay have received a USCIS OnlineAccount Access Notice issuing you aUSCIS Online Account Number. You mayfind your USCIS Online Account Numberat the top of the notice. The USCIS OnlineAccount Number is not the same as an A-Number. If you were issued a USCISOnline Account Number, enter it in thespace provided.

Item Number 9. Alien RegistrationNumber (A-Number) (if any). An AlienRegistration Number, otherwise known asan “A-Number,” is typically issued topeople who apply for, or are granted,certain immigration benefits. In addition toUSCIS, ICE, CBP, and DOS may also issuean A-Number to certain foreignnationals. If you were issued an A-Number, type or print it in the spacesprovided. If you have more than one A-Number, use the space provided in Part 9.Additional Information to provide theinformation. If you do not have an A-

use Part 10. Additional Information toprovide other names used.

Item Number 10. Date of Birth. Provideyour date of birth in mm/dd/yyyy format inthe space provided. For example, type orprint October 5, 1967 as 10/05/1967.

Item Number 11. Gender. Select the boxthat indicates whether you are male orfemale.

Item Number 12. USCIS Online AccountNumber (if any).

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Item Number 13. Alien RegistrationNumber (A-Number) (if any). Provideyour A-Number. Your A-Number is thenumber used to identify your immigrationrecords. It begins with an “A” and can befound on correspondence that has beenreceived from the Department of HomelandSecurity (DHS) or USCIS. If you do nothave an A-Number, type or print “N/A.”


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Number or if you cannot remember it, leavethis space blank.

Part 2. Clinical Office Locations

If you intend to perform immigrationmedical examinations in more than onelocation, provide the details for eachadditional location in Part 9. AdditionalInformation.

Item Numbers 1. - 5. Name and PhysicalAddress of the Clinic/Practice. Providethe name, physical address, telephonenumber, fax number, and email address ofthe clinic or practice where you intend toperform immigration medical examinationsif granted civil surgeondesignation. Failure to provide thisinformation may result in the denial ofyour Form I-910.

Part 2. Clinical Office Locations

Provide the following information aboutthe locations where you seek to performimmigration medical examinations. If youintend to perform immigration medicalexaminations in more than one location,provide the details for each additionallocation in Part 10. AdditionalInformation.

You must provide the followinginformation. Failure to provide thisinformation may result in the denial of yourapplication. USCIS displays informationregarding a clinic/practice location andcontact information on our website forpeople who wish to find a civil surgeon.USCIS will use the contact informationlisted below for all civil surgeon-relatedcommunications.

Item Number 1. Name of theClinic/Practice. Provide the name of eachclinic or practice where you intend toperform immigration medical examinationsif granted civil surgeon designation.

Item Number 2. Physical Address of theClinic/Practice. Provide the physicaladdress.

The physical address is the address whereyou are practicing medicine and whereapplicants will come to have the medicalexamination performed. The physicaladdress must match the location of yourmedical clinic or practice. The addressmust be in the United States.

Item Numbers 3. - 9. Clinic/PracticeContact Information. Provide the countyof practice, contact information, telephonenumber, fax number, email address, andother relevant information for each clinic orpractice where you intend to performimmigration medical examinations if


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NOTE: You must currently have activepractices at the locations where you arerequesting to perform immigration medicalexaminations. USCIS will not grant civilsurgeon designation for locations whereyou intend to practice only in the future.

NOTE REGARDING PHYSICALADDRESS: The physical address is theaddress where you are practicing medicineand where applicants will come to have themedical examination performed. Thephysical address must match the location ofyour medical clinic or practice.

Item Numbers 6. - 14. Additional OfficeInformation. You may submit additionalinformation to USCIS for inclusion in thepublic list of civil surgeons. USCISdisplays this information on our website forapplicants who want to find a civilsurgeon. USCIS will update the public listwith this information.

Part 3. Information About Your Statusin the United States

Item Numbers 1. - 4. Provide informationabout the immigration status you weregranted in the United States that allows youto work and practice medicine in the UnitedStates. A physician meeting theprofessional qualifications for civil surgeondesignation can receive designation as acivil surgeon only if authorized to work inthe United States. Specify whether you area U.S. citizen or national, a lawfulpermanent resident, a nonimmigrantauthorized to work as a physician in theUnited States, or an immigrant in anotherstatus that would allow you to practicemedicine in the United States. Attach

granted civil surgeon designation.

Item Numbers 10. - 11. Mailing Addressof the Clinic/Practice. Provide the mailingaddress of the Clinic/Practice if differentthan the physical address of the clinic orpractice where you intend to performimmigration medical examinations ifgranted civil surgeon designation. Theaddress must be in the United States.

NOTE: You must currently have activepractices at the locations where you arerequesting to perform immigration medicalexaminations. USCIS will not grant civilsurgeon designation for locations whereyou intend to practice in the future or whereyou have practiced in the past.

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Part 3. Information About Your Statusin the United States

Item Numbers 1. - 3. Provide informationabout your immigration status in the UnitedStates that allows you to work and practicemedicine in the United States. A physicianmeeting the professional qualifications forcivil surgeon designation can receivedesignation as a civil surgeon only ifauthorized to work in the United States.Specify whether you are a U.S. citizen ornational, a lawful permanent resident, or anonimmigrant authorized to work as aphysician in the United States. Attachevidence establishing your lawful status inthe United States.


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evidence establishing your legal status inthe United States.

1. If you select Item Number 1., submitproof that you are a U.S. citizen or national,such as a copy of a U.S. passport, birthcertificate, or Certificate of Naturalization.

2. If you select Item Number 2., submit acopy of your valid Form I-551, PermanentResident Card. If you are currently seekingto renew or replace your Form I-551,submit evidence your Form I-90,Application to Replace Permanent ResidentCard, is pending or approved. For moreinformation, visit www.uscis.gov/green-card/after-green-card-granted.

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3. If you select Item Number 3.a., youmust also provide the informationrequested in Item Numbers 3.b. - 3.h.

A. Item Number 3.b. Date of LastArrival in the U.S.(mm/dd/yyyy). Provide the date of yourlast arrival to the United States.

B. Item Number 3.c. Form I-94, Arrival-Departure Record. If CBP or USCISissued you a Form I-94, Arrival-DepartureRecord, provide your Form I-94 numberand date that your authorized period of stayexpires or expired (as shown on your FormI-94). The Form I-94 number also isknown as the Departure Number on someversions of Form I-94.

NOTE: If you were admitted to the UnitedStates by CBP at an airport or seaport afterApril 30, 2013, CBP may have issued youan electronic Form I-94 instead of a paperForm I-94. You may visit the CBP websiteat www.cbp.gov/i94 to obtain a paperversion of an electronic Form I-94. CBPdoes not charge a fee for thisservice. Some travelers admitted to the

If you select Item Number 1., submitproof that you are a U.S. citizen or national,such as a copy of an unexpired U.S.passport, birth certificate, or Certificate ofNaturalization.

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If you select Item Number 2., submit acopy of your valid Form I-551, PermanentResident Card. If you are currently seekingto renew or replace your Form I-551,submit evidence that your Form I-90,Application to Replace Permanent ResidentCard, is pending or approved. For moreinformation, visit www.uscis.gov/green-card/after-green-card-granted.

If you select Item A. in Item Number 3.,you must also provide the informationrequested in Items B. - H. in Item Number3.

Item B. Date of Last Arrival in the U.S.(mm/dd/yyyy). Provide the date of your lastarrival to the United States.

Item C. Form I-94, Arrival-DepartureRecord. If CBP or USCIS issued you aForm I-94, Arrival-Departure Record,provide your Form I-94 number and datethat your authorized period of stay expiresor expired (as shown on your Form I-94).The Form I-94 number is also known as theArrival/Departure Number on someversions of Form I-94.

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United States at a land border, airport, orseaport after April 30, 2013, with apassport or travel document, who wereissued a paper Form I-94 by CBP, may alsobe able to obtain a replacement Form I-94from the CBP website without charge. Ifyou cannot obtain your Form I-94 from theCBP website, you may obtain it by filingForm I-102, Application forReplacement/Initial Nonimmigrant Arrival-Departure Record, with USCIS. USCISdoes charge a fee for this service. See theUSCIS website at www.uscis.gov/I-102 formore information.

C. Item Numbers 3.d. - 3.h. Passportand Travel Document Numbers. If youused a passport or travel document to travelto the United States, enter either thepassport or travel document information inthe appropriate space on the application,even if the passport or travel document iscurrently expired.

4. Select Item Number 4. if USCIS issuedyou an Employment AuthorizationDocument (EAD) that authorizes you towork in the United States. Attach a copy ofyour valid, unexpired EAD as proof you areauthorized to work in the United States.

Part 5. Medical Degrees

Item Numbers 1.a. - 2.c. Only doctors ofmedicine (M.D.) and doctors of osteopathy(D.O.) may receive designation as civilsurgeons. Provide the following:

1. The names of the schools you attended;

2. The dates of your attendance; and

3. The type of medical degrees you earned.

Attach a copy of each of your medicaldegrees to your Form I-910.

Items D. - G. Passport and TravelDocument Numbers. If you used apassport or travel document to travel to theUnited States, enter either the passport ortravel document information in theappropriate space on the application, evenif the passport or travel document iscurrently expired.

Answer Item H. in Item Number 3., ifUSCIS issued you an EmploymentAuthorization Document (EAD) thatauthorizes you to work in the United States.Attach a copy of your valid, unexpiredEAD as proof you are authorized to work inthe United States.

Part 4. Medical Degrees

Only doctors of medicine (M.D.) anddoctors of osteopathy (D.O.) may receivedesignation as civil surgeons. Provide thefollowing:

1. The name(s) of the school(s) youattended;

2. The dates of your attendance andgraduation; and

3. The type of medical degree(s) youearned.

If you need extra space to complete thissection, use the space provided in Part 10.Additional Information.

Attach a copy of your medical degree(s) toyour Form I-910. A copy of the originalmedical school diploma is required. If it is


15

Part 4. Medical Licenses

Item Numbers 1.a. - 2.d. You must have alicense to practice medicine in each U.S.state or U.S. territory in which you seek toperform immigration medicalexaminations. For each U.S. state or U.S.territory in which you seek to performimmigration medical examinations, providethe following:

1. The name of the U.S. state or U.S.territory that issued your medical license;

2. The medical license number;

3. The date the medical license was issued;and

4. The date the medical license expires.

Attach a copy of each of your medicallicenses to your Form I-910.

[Page 7]

Part 6. Professional Experience

a foreign language diploma, a full Englishtranslation must be submitted with theforeign document. The translator must signa certification that the English languagetranslation is complete and accurate, andthat he or she is competent to translate fromthe foreign language into English. Thecertification must include the translator’ssignature. A Certificate from EducationalCommission for Foreign MedicalGraduates is not acceptable for thisrequirement.

Part 5. Medical Licenses

You must have an active and unrestrictedlicense to practice medicine in each U.S.state or U.S. territory where you seek toperform immigration medicalexaminations. For each U.S. state or U.S.territory where you seek to performimmigration medical examinations, fill outthe chart with the following information:

1. The name of the U.S. state or U.S.territory that issued your medical license;

2. The medical license number;

3. The date the medical license was issued;

[Page 7]

4. The date the medical license expires; and

5. Whether the medical license is in goodstanding.

NOTE: A medical license is in goodstanding if it is active and unrestricted. Ifany medical license was ever not in goodstanding, you must provide documentationof any previous, current, or pendingrestriction.

Attach a copy of each of your medicallicenses to your Form I-910.

Part 6. Professional Experience


16

Item Numbers 1.a. - 2.h. To receivedesignation as a civil surgeon, you mustestablish you have practiced medicine as aphysician (M.D. or D.O.) for at least fouryears. Provide the following information tocover a period of at least four years:

1. The names of each employer;

2. The dates of your employment with eachemployer; and

3. The contact information for eachemployer.

NOTE: In calculating whether you meetthe four-year practice requirement as aphysician, do not count your post-graduatemedical training in an internship orresidency program. You can, however,count the time you practiced medicine onthe basis of a post-residencyfellowship. Submit evidence establishingyour professional experience, such asevaluations, certificates of completion,business tax returns and business licenses(for self-employed physicians), or letters ofemployment verification.

Part 7. Applicant’s Statement, ContactInformation, Declaration, Certification,and Signature

Item Numbers 1. - 5.b. If someoneassisted you in completing the application,

Item Numbers 1. - 2. To receivedesignation as a civil surgeon, you mustestablish you have practiced medicine as aphysician (M.D. or D.O.) for at least fouryears in the U.S. Provide the followinginformation to cover a period of at leastfour years:

1. The names of each employer;

2. The dates of your employment with eachemployer; and

3. The contact information for eachemployer.

If you need extra space to complete thissection, use the space provided in Part 10.Additional Information.

NOTE: In calculating whether you meetthe four-year practice requirement as aphysician, do not count your post-graduatemedical training in an internship orresidency program. You can, however,count the time you practiced medicine onthe basis of a post-residency fellowship.Submit evidence establishing yourprofessional experience, such as letters ofemployment verification, evaluations,certificates of completion of fellowshipprogram, or medical liability or malpracticeinsurance policy. Letters of employment oremployee evaluation should be on thecompany letterhead, include your dates ofemployment, position(s) held, jobdescription, and the name, title/position andsignature of the person authorized to verifythe employment. A medical liability ormalpractice insurance policy, by itself, isinsufficient to establish professionalexperience, but may be submitted tosupplement other evidence listed above. Ifyou are/were self-employed, submit copiesof your business tax returns and yourbusiness license(s) or tax receipt(s)covering the tax return periods.

Part 7. Applicant’s Statement, ContactInformation, Certification, andSignature

Item Numbers 1. - 6. Select theappropriate box to indicate whether you


17

select the box indicating that you used apreparer. Further, you must sign and dateyour application and provide your daytimetelephone number, mobile telephonenumber (if any), and email address (ifany). Every application MUST contain thesignature of the applicant. A stamped ortypewritten name in place of a signature isnot acceptable.

Part 8. Contact Information,Declaration, and Signature of the PersonPreparing this Application, if OtherThan the Applicant

Item Numbers 1.a. - 9.b. This sectionmust contain the signature of the personwho completed your application, if otherthan you, the applicant. If the person whocompleted this application is associatedwith a business or organization, that personshould complete the business ororganization name and addressinformation. Anyone who helped youcomplete this application MUST sign anddate the application. A stamped ortypewritten name in place of a signature isnot acceptable. If the person who helpedyou prepare your application is an attorneyor accredited representative, he or she may

read this application yourself or whetheryou had an interpreter assist you. Ifsomeone assisted you in completing theapplication, select the box indicating thatyou used a preparer. Further, you mustsign and date your application and provideyour daytime telephone number, mobiletelephone number (if any), and emailaddress (if any). Every application MUSTcontain the signature of the applicant. Astamped or typewritten name in place of asignature is not acceptable. Your signaturewill be kept on record to verify thesignature on any submitted Form I-693.

Part 8. Interpreter’s ContactInformation, Certification, andSignature

Item Numbers 1. - 7. If you used anyoneas an interpreter to read the Instructions andquestions on this application to you in alanguage in which you are fluent, theinterpreter must fill out this section;provide his or her name, the name andaddress of his or her business ororganization (if any), his or her daytimetelephone number, his or her mobiletelephone number (if any), and his or heremail address (if any). The interpreter mustsign and date the application.

[Page 8]

Part 9. Contact Information,Declaration, and Signature of the PersonPreparing this Application, if OtherThan the Applicant

Item Numbers 1. - 9. This section mustcontain the signature of the person whocompleted your application, if other thanyou, the applicant. If the same individualacted as your interpreter and your preparer,that person should complete both Part 8.and Part 9. If the person who completedthis application is associated with abusiness or organization, that person shouldcomplete the business or organization nameand address information. Anyone whohelped you complete this applicationMUST sign and date the application. Astamped or typewritten name in place of asignature is not acceptable. If the person


18

also need to submit a completed Form G-28, Notice of Entry of Appearance asAttorney or Accredited Representative,along with your application.

NOTE: Select Item Number 7. if thepreparer may act as a secondary point ofcontact for you, if USCIS is unable tocontact you using the information providedin Part 2. Clinical Office Locations.

Part 9. Additional Information

Item Numbers 1.a - 7.d. If you need extraspace to provide any additional informationwithin this application, use the spaceprovided in Part 9. AdditionalInformation. If you need more space thanwhat is provided in Part 9., you may makecopies of Part 9. to complete and file withyour application, or attach a separate sheetof paper. Type or print your name andCSID Number (if any) at the top of eachsheet; indicate the Page Number, PartNumber, and Item Number to which youranswer refers; and sign and date eachsheet.

You may also submit a statement withadditional information on a separate sheetof paper, but you must annotate in Part 9.that you are attaching a separate sheet. Youmust submit the separate sheet at the sametime you submit your Form I-910. Type orprint your name and CSID Number (if any)at the top of each separate sheet; indicatethe Page Number, Part Number, andItem Number of Form I-910 to which theadditional information relates; and sign anddate each sheet.

We recommend that you print or save acopy of your completed application toreview in the future and for yourrecords.

who helped you prepare your application isan attorney or accredited representative, heor she may also need to submit a completedForm G-28, Notice of Entry of Appearanceas Attorney or Accredited Representative,along with your application.

NOTE: Select Item Number 7. if thepreparer may act as a secondary point ofcontact for you, if USCIS is unable tocontact you using the information providedin Part 2. Clinical Office Locations.

Part 10. Additional Information

Item Numbers 1. - 7. If you need extraspace to provide any additional informationwithin this application, use the spaceprovided in Part 10. AdditionalInformation. If you need more space thanwhat is provided in Part 10., you maymake copies of Part 10. to complete andfile with your application, or attach aseparate sheet of paper. Type or print yourname and CSID Number (if any) at the topof each sheet; indicate the Page Number,Part Number, and Item Number to whichyour answer refers; and sign and date eachsheet.

You may also submit a statement withadditional information on a separate sheetof paper, but you must annotate in Part 10.that you are attaching a separate sheet. Youmust submit the separate sheet at the sametime you submit your Form I-910. Type orprint your name and CSID Number (if any)at the top of each separate sheet; indicatethe Page Number, Part Number, andItem Number of Form I-910 to which theadditional information relates; and sign anddate each sheet.

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Page 8,What Is the Filing Fee?

[Page 8]

What Is the Filing Fee?

The filing fee for Form I-910 is $785.

[Page 8]

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Exception: There is no filing fee for anapplication submitted by a medical officerin the U.S. Armed Forces or from a civilianphysician employed by the U.S.Government who examines members andveterans of the of the U.S. Armed Forcesand their dependents at a military,Department of Veterans Affairs, or U.S.Government facility in the United States.

NOTE: The filing fee is not refundable,regardless of any action USCIS takes onthis application. DO NOT MAILCASH. You must submit all fees in theexact amounts.

Payments by Check or Money Order

Use the following guidelines when youprepare your check or money order for theForm I-910 filing fee:

1. The check or money order must bedrawn on a bank or other financialinstitution located in the United States andmust be payable in U.S. currency; and

2. Make the check or money order payableto U.S. Department of HomelandSecurity.

NOTE: Spell out U.S. Department ofHomeland Security; do not use the initials“USDHS” or “DHS.”

Notice to Those Paying by Check. If yousend USCIS a check, we will convert it intoan electronic funds transfer (EFT). Thismeans we will copy your check and use theaccount information on it to electronicallydebit your account for the amount of thecheck. The debit from your account willusually take 24 hours and your bank willshow it on your regular account statement.

You will not receive your original checkback. We will destroy your original check,but will keep a copy of it. If USCIS cannotprocess the EFT for technical reasons, youauthorize us to process the copy in place ofyour original check. If your check isreturned as unpayable, we will re-submit

Exception: Physicians receiving blanketcivil surgeon designations are not subject toa fee for receiving the blanket designation.For more information, please visithttp://www.uscis.gov/civilsurgeons.

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[Page 9]


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the payment to the financial institution onetime. If the check is returned as unpayablea second time, we will reject yourapplication and charge you a returnedcheck fee.

Payments by Credit Card

If you are filing your form at a USCISLockbox facility, you can pay your filingfee using a credit card. Please see Form G-1450, Authorization for Credit CardTransactions, at www.uscis.gov/G-1450 formore information.

How To Check If the Fees Are Correct

Form I-910’s filing fee is current as of theedition date in the lower left corner of thispage. However, because USCIS feeschange periodically, you can verify that thefee is correct by following one of the stepsbelow.

1. Visit the USCIS website atwww.uscis.gov, select “FORMS,” andcheck the appropriate fee; or

2. Call the USCIS National CustomerService Center at 1-800-375-5283 and askfor fee information. For TTY (deaf or hardof hearing) call: 1-800-767-1833.

If you are filing your application at aUSCIS Lockbox facility, you can pay yourfiling fee using a credit card. Please seeForm G-1450, Authorization for CreditCard Transactions, at www.uscis.gov/G-1450 for more information.

NOTE: By completing this transaction,you agree that you have paid for agovernment service and that the filing fee,biometric services fee and all relatedfinancial transactions are final and notrefundable, regardless of an action USCIStakes on an application, petition or request,or how long USCIS takes to reach adecision. DO NOT MAIL CASH. Youmust submit all fees in the exact amounts.

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2. Visit the USCIS Contact Center athttps://www.uscis.gov/contactcenter toget answers to your questions and connectwith a live USCIS representative. TheUSCIS Contact Center providesinformation in English and Spanish. ForTTY (deaf or hard of hearing) call: 1-800-767-1833.

Page 8,Where To File?

[Page 8]

Where To File?

Please see our website at www.uscis.gov/I-910 or call our National Customer ServiceCenter at 1-800-375-5283 for the most

[Page 9]

Where To File?

Please see our website at www.uscis.gov/I-910 or visit the USCIS Contact Center athttps://www.uscis.gov/contactcenter to


21

current information about where to file thisapplication. For TTY (deaf or hard ofhearing) call: 1-800-767-1833.

connect with a USCIS representative forthe most current information about whereto file this application. The USCIS ContactCenter provides information in English andSpanish. For TTY (deaf or hard of hearing)call: 1-800-767-1833.

Page 9,Where Is Civil SurgeonInformation Listed?

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Where Is Civil Surgeon InformationListed?

USCIS provides a list of civil surgeons forpublic use. You can access the list in twoways:

1. Visit the USCIS website atmy.uscis.gov/findadoctor and enter a zipcode or address; or

2. Call the USCIS National CustomerService Center at 1-800-375-5283 andfollow the instructions in the automatedmenu. For TTY (deaf or hard of hearing)call: 1-800-767-1833.

[Page 9]

Where Is Civil Surgeon InformationListed?

We provide a list of civil surgeons forpublic use. You can access the list in twoways:

1. Visit the USCIS website atmy.uscis.gov/findadoctor and enter a zipcode or address; or

2. Visit the USCIS Contact Center athttps://www.uscis.gov/contactcenter toget answers to your questions and connectwith a live USCIS representative. TheUSCIS Contact Center providesinformation in English and Spanish. ForTTY (deaf or hard of hearing) call: 1-800-767-1833.

Page 9,When and How Do IUpdate My Civil SurgeonInformation?

[Page 9]

When and How Do I Update My CivilSurgeon Information?

You should notify USCIS within 15 daysof any changes relevant to yourdesignation, including address and othercontact information, practice location, andmedical license restrictions, suspensions, orrevocations.

Visit the USCIS website atwww.uscis.gov/I-910 for the most currentinformation about how and where to submitan update to your civil surgeoninformation.

NOTE: If the change is an update to yourcontact information that involves practicingin a new U.S. state or U.S. territory, thenyou may not perform immigration medicalexaminations in the new U.S. state or U.S.territory until USCIS approves thechange. In this case, you must submit yournew contact information to USCIS with

[Page 9]

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Visit the USCIS website atwww.uscis.gov/I-910 for the most currentinformation about how and where to submitan update to your civil surgeoninformation.

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22

evidence you are licensed to practicemedicine in the new U.S. state or U.S.territory in which you seek to performimmigration medical examinations.

USCIS will also conduct compliancereviews or audits to ensure the accuracy ofcivil surgeon information. As part of thesecompliance reviews or audits, USCIS maycontact you to verify some or all of theinformation provided on Form I-910. IfUSCIS is unable to verify your continuedeligibility for designation or confirm yourcontact information, or if USCISdetermines you are no longer practicingmedicine or performing immigrationmedical examinations, USCIS may revokeor terminate your designation and removeyou from the public list.

[Page 10]

Visit the USCIS Contact Center athttps://www.uscis.gov/contactcenter oremail [email protected] toget answers to your questions about civilsurgeon designation applications,revocations, and motions to reopen orquestions about completing Form I-910.

Page 9,Processing Information

[Page 9]

Processing Information

Initial Processing. Once USCIS acceptsyour application, we will check it forcompleteness. If you do not completely fillout this application, you will not establish abasis for your eligibility and USCIS mayreject or deny your application.

Requests for More Information. USCISmay request that you provide moreinformation or evidence to support yourapplication. We may also request that youprovide the originals of any copies yousubmit. If we request an original documentfrom you, it will be returned to you afterUSCIS determines it no longer needs youroriginal.

Decision. The decision on Form I-910involves a determination of whether you

[Page 10]

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23

have established eligibility for thedesignation you are seeking. USCIS willnotify you of the decision in writing.

Page 9,USCIS Forms andInformation

[Page 9]

USCIS Forms and Information

To ensure you are using the latest versionof this application, visit the USCIS websiteat www.uscis.gov where you can obtain thelatest USCIS forms and immigration-related information. If you do not haveinternet access, you may order USCISforms by calling the USCIS Contact Centerat 1-800-375-5283. The USCIS ContactCenter provides information in English andSpanish. For TTY (deaf or hard of hearing)call: 1-800-767-1833.

Instead of waiting in line for assistance atyour local USCIS office, you can schedulean appointment online atwww.uscis.gov. Select “Make anAppointment” and follow the screenprompts to set up your appointment. Onceyou finish scheduling an appointment, thesystem will generate an appointment noticefor you.

[Page 10]

USCIS Forms and Information

To ensure you are using the latest versionof this application, visit the USCIS websiteat www.uscis.gov where you can obtain thelatest USCIS forms and immigration-related information. If you do not haveinternet access, you may call the USCISContact Center at 1-800-375-5283 and askthat we mail a form to you. The USCISContact Center provides information inEnglish and Spanish. For TTY (deaf orhard of hearing) call: 1-800-767-1833.

Please visit us atwww.uscis.gov/contactcenter to get basicinformation about immigration services andask questions about a pending case.Through our digital self-help tools and liveassistance, the USCIS Contact Centerprovides a pathway for you to getconsistent, accurate information andanswers to immigration case questions.

Page 10,Penalties

[Page 10]

Penalties

If you knowingly and willfully falsify orconceal a material fact or submit a falsedocument with your Form I-910, we willdeny your Form I-910 and may deny anyother immigration benefit. In addition, youwill face severe penalties provided by lawand may be subject to criminalprosecution.

[Page 10]

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Page 10,USCIS Compliance Reviewand Monitoring

[Page 10]

USCIS Compliance Review andMonitoring

By signing this application, you have statedunder penalty of perjury (28 U.S.C. section1746) that all information anddocumentation submitted with thisapplication are complete, true, andcorrect. You also authorize the release ofany information from your records that

[Page 10]

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USCIS may need to determine youreligibility for the designation you areseeking and consent to USCIS verifyingsuch information.

DHS has the authority to verify anyinformation you submit to establisheligibility for the designation you areseeking at any time. USCIS’ legalauthority to verify this information is in 8U.S.C. sections 1103 and 1222(b) and 8CFR 232.2(b). To ensure compliance withapplicable laws and authorities, USCISmay verify information before or after yourcase is decided.

Agency verification methods may include,but are not limited to: review of publicrecords and information; contact throughwritten correspondence, the internet, fax,other electronic transmission, or telephone;unannounced physical site inspections ofmedical clinics or practices; andinterviews. USCIS will use informationobtained through verification to assess yourcompliance with the laws and to determineyour eligibility for designation.

Subject to the restrictions under 8 CFR103.2(b)(16), USCIS will provide you withan opportunity to address any adverse orderogatory information that may resultfrom a USCIS compliance review,verification, or site visit after a formaldecision is made on your case or after theagency has initiated an adverse actionwhich may result in revocation ortermination of an approval.

DHS has the authority to verify anyinformation you submit to establisheligibility for the designation you areseeking at any time. USCIS’ legal authorityto verify this information is in 8 U.S.C.sections 1103, 1155, and 1184, and 8 CFRparts 103, 204, 205, and 214. To ensurecompliance with applicable laws andauthorities, USCIS may verify informationbefore or after your case is decided.

[Page 11]

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Page 10,DHS Privacy Notice

[Page 10]

DHS Privacy Notice

AUTHORITIES: The informationrequested on this form, and the associatedevidence, is collected under theImmigration and Nationality Act section232.

PURPOSE: The primary purpose forrequesting the requested information is todetermine whether you are eligible to be

[Page 11]

DHS Privacy Notice

AUTHORITIES: The informationrequested on this application, and theassociated evidence, is collected under theImmigration and Nationality Act section232.

PURPOSE: The primary purpose forproviding the requested information on thisapplication is to determine whether you are


25

designated as a USCIS CivilSurgeon. DHS will use the informationyou provide to grant or deny theimmigration benefit you are seeking.

DISCLOSURE: Providing thisinformation is voluntary. However, failureto provide the requested information, andany requested evidence, may delay a finaldecision in your case or result in denial ofyour request to be designated as a CivilSurgeon.

ROUTINE USES: DHS may share theinformation you provide on this form withother Federal, state, local, and foreigngovernment agencies and authorizedorganizations. DHS follows approvedroutine uses, as described in the associatedpublished system of records notices [DHS-USCIS-007 - Benefits Information System]and as described in the Privacy ImpactAssessment [DHS/USCIS/PIA-067 CivilSurgeon Designation] which you can findat www.dhs.gov/privacy. DHS may alsoshare the information, as appropriate, forlaw enforcement purposes or in the interestof national security.

eligible to be designated as a USCIS CivilSurgeon. DHS uses the information youprovide to grant or deny the immigrationbenefit you are seeking.

DISCLOSURE: The information youprovide is voluntary. However, failure toprovide the requested information,including your Social Security number (ifapplicable), and any requested evidence,may delay a final decision or result indenial of your request to be designated as aCivil Surgeon.

ROUTINE USES: DHS may share theinformation you provide on this applicationwith other Federal, state, local, and foreigngovernment agencies and authorizedorganizations. DHS follows approvedroutine uses described in the associatedpublished system of records notices [DHS-USCIS-007 - Benefits Information System]and as described in the Privacy ImpactAssessment [DHS/USCIS/PIA-067 CivilSurgeon Designation] which you can findat www.dhs.gov/privacy. DHS may alsoshare this information, as appropriate, forlaw enforcement purposes or in the interestof national security.

Page 11,Is Your ApplicationComplete?

[Page 11]

Is Your Application Complete?

Ensure you have completed the followingactions before you file Form I-910 withUSCIS.

Did you fill out the application properly,leaving spaces blank on any questions thatdid not apply to you?

Did you sign and date your applicationwhere required?

If you had someone else prepare theapplication on your behalf, did that personcomplete Part 8. Contact Information,Declaration, and Signature of the PersonPreparing this Application, if OtherThan the Applicant and sign and date theapplication?

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26

If the person who prepared the applicationon your behalf was an attorney, did theattorney submit Form G-28 with theapplication?

Did you include a check or money orderaccording to the What Is the Filing Feesection of these Instructions?

Did you attach the required documentationor evidence, including proof of yourimmigration status in the United States,copies of medical degrees and current U.S.state or U.S. territory medical licenses, andproof that you meet the professionalexperience requirement because you havepracticed medicine as a physician (M.D. orD.O.) for at least four years?

If you intend to perform immigrationmedical examinations in more than onelocation, did you provide details for eachadditional location in Part 9. AdditionalInformation?


Documents

INSTRUCTIONS Form I-910, Application for Civil Surgeon