Work Authorization Revocation Appeal Form

Work Authorization Revocation Appeal Form
Use this form to submit an appeal regarding a work authorization revocation and provide the details needed for review.
Applicant Information
Full Name
First NameMiddle NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Revocation Details
Employer or issuing organization name
Work authorization document or case reference number
Date revocation notice was received
MonthDayYear
Date
Date of revocation
MonthDayYear
Date
Appeal Basis and Supporting Evidence
Reason for Appeal
Requested Outcome or Remedy
Supporting Documents or Evidence
Cancelof
Should be Empty: