I-905, Application for Authorization to Issue Certification for Health Care Workers

Use this form if you work with an organization and want to apply for authorization to issue certificates to health care workers.

Forms and Document Downloads

Form I-905 (PDF, 320.59 KB)

Instructions for Form I-905 (PDF, 264.26 KB)

Form Details

11/10/20. We will also accept the 10/30/11 and 02/11/14 editions. You can find the edition date at the bottom of the page on the form and instructions.

Dates are listed in mm/dd/yy format.

If you need help downloading and printing forms, read our instructions.

Mail your application to:

Nebraska Service Center
P.O. Box 82521
Lincoln, NE 68501-2521

Filing Tips: Go to our Form Filing Tips page for information on how to help ensure we will accept your application.

Don’t forget to sign your form. We will reject any unsigned form.

$230.

We accept fees in the form of a money order, personal check, or cashier’s check. If you pay by check, you must make your check payable to the U.S. Department of Homeland Security.

When you send a payment, you agree to pay for a government service. Filing and biometric service fees are final and nonrefundable, regardless of any action we take on your application, petition, or request, or if you withdraw your request.

You must submit two complete copies of this application.

Last Reviewed/Updated:

11/30/2020