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
2 digit month, 2 digit day, 4 digit yearDate
Date of revocation
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Appeal Basis and Supporting Evidence
Reason for Appeal
Requested Outcome or Remedy
Supporting Documents or Evidence
Cancelof
Should be Empty: