Part 1: Type of Application

NOTE: Select the box for Item Number 1.a., 1.b., or 2. If applicable, select the box for Item Number 3.a. or 3.b. For Item Number 4., enter the name of the designated TPS country.

NOTE: If you have previously applied or have a pending application for TPS, but do not currently have TPS, select Item Number 1.a. and describe each time that you previously applied, including the receipt number (if available) and the outcome (if any) of each application. If you currently have a pending TPS application, please also describe when you filed it and the application receipt number (if available) in Part 11. Additional Information. If you do not recall or have incomplete information on your prior TPS applications, please provide the information you have, even if incomplete.

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2. If you selected Item Number 1.b., please indicate who granted you TPS.

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Are you also filing a request for employment authorization?

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Part 2: Information About You (continued)

Other Names Used

Provide all other names you have used since birth, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 11. Additional Information.

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Part 2: Information About You (continued)

U.S. Mailing Address

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Step 3: Personal Information

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