Date of issuing: –/–/—- [dd / mm / yyyy]
Surname of the Card Holder: __________________________________________
First Name of the Card Holder: ________________________________________
USCIS No. : ______________________________
Country of Birth: ___________________________
Date of Birth: –/–/—- [dd / mm / yyyy]
Port-of-entry or the office where the adjustment status was granted: ______________
Sex: Male/ Female
Date from when the card holder becomes a permanent resident: –/–/—- [dd / mm / yyyy]
Card Expiry Date: –/–/—- [dd / mm / yyyy]
________________________ _______________________
(Signature of the Card Holder) (Signature of the Issuing Officer)