The applicant completes most of this 11-page waiver application, but when the inadmissibility ground is a Class A tuberculosis condition, Part 11 needs a physician at the local city or county health department where the applicant will live. That physician agrees to provide the TB care the applicant needs after arrival and to report on the initial evaluation.
The local health department physician signs the Physician's Certification and the health department statement in Part 11, and a state health department official endorses it. The applicant signs a statement agreeing to report for examination and treatment, and the applicant or sponsor arranges the care.
Download the current version from the source each time; forms change without notice.
Application for Waiver of Grounds of Inadmissibility
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
A physician at the local city or county health department in the area where the applicant plans to live signs the Physician's Certification in ink and identifies the health department. The State Health Department Official for that area then endorses it, confirming the local department is within their jurisdiction. The applicant signs the first statement.
Only for health-related grounds. The Class A TB statement in Part 11 is for the local health department physician. For a 212(g)(3) waiver based on a physical or mental disorder with associated harmful behavior, the applicant attaches a separate per-case medical report covering diagnosis, tests, prognosis and treatment recommendations.