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The civil surgeon will fill in this field
Street Number and Name*
?
Example: 1243 West Glenn Ave form
Apt. Ste. Flr.
City or Town*
ZIP Code*
State*
Province
Please leave empty
Postal Code
Country
A. Gender*
B. City/Town/Village of Birth*
C. Date of Birth*
D. Country of Birth*
E. Registration Number (A-Number) (if any)
A -
If applicable, this 9 digit number can be found on letters sent to you from USCIS and will appear with an "A" in front of the number. It can also be found on the USA Employment Authorization Card and is listed as your USCIS #.
F. USCIS Online Account Number (if any)
I am eligible for completion of the vaccination record portion only, because I previously completed an overseas immigration medical examination, signed by a panel physician (refugee or derivative asylee adjustment of status applicants under Immigration and Nationality Act (INA) section 209 and K nonimmigrant visa holders applying for adjustment of status).
Form I-693 Edition 03/09/2
Page 1
Provide your daytime telephone number, mobile telephone number (if any), and email address (if any).
I certify, under penalty of perjury, that I provided or authorized all of the responses and information contained in and submitted with my application, I read and understand or, if interpreted to me in a language in which I am fluent by the interpreter listed in Part 3., understood, all of the responses and information contained in, and submitted with, my form, and that all of the responses and the information are complete, true, and correct. I understand the purpose of this immigration medical examination, and I authorize the required tests and procedures to be completed. If it is determined that I willfully misrepresented a material fact or provided false or altered information or documents with regard to my immigration medical examination, I understand that any immigration benefit I derived from this immigration medical examination may be revoked, that I may be removed from the United States, and that I may be subject to civil or criminal penalties. Furthermore, I authorize the release of any information from any and all of my records that USCIS may need to determine my eligibility for an immigration request and to other entities and persons where necessary for the administration and enforcement of U.S. immigration law.
Page 2
Please review the information you provided. You will NOT be able to change it in the next screen!
