| Home
Phone |
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| Work
Phone |
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| Fax
No. |
|
| E-mail
Address |
|
Information About You
:
|
|
| Complete Name (Last Name,
Middle Name, First name) |
|
| Current US Address (Street
No. and Name, State, Apt No., City, State, Zip Code) |
|
| Date of Birth
(Month/Day/Year) |
|
| Place of
Birth |
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| Social Security No. and/or
Tax ID no. |
-- |
| A# (if any) |
|
| Date of Last Arrival in
U.S. |
|
| I-94# |
|
| Current INS
Status |
|
| Expires on |
|
Processing
Information:
|
|
| Current Occupation
|
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| Your Mother's First
Name |
|
| Your Father's First
Name |
|
| Give your name EXACTLY as
it appears on I-94 card |
|
| Place of last entry into
the U.S. (city/state) |
|
| in what status did you
last enter |
|
| U.S. Visa Control
No. |
|
| Consulate where visa was
issued |
|
| Date Visa
issued |
|
| Sex |
MaleFemale |
| Marital
Status |
Single
MarriedWidowedDivorced |
| List present
HUSBAND/WIFE, ALL SONS/DAUGHTERS |
|
| Complete Name (Last Name,
Middle Name, First name) |
|
| Date of Birth
(Month/Day/Year) |
|
| Country of
Birth |
|
| Relationship |
|
| Applying with
you |
YesNo |
|
|
| Complete Name (Last Name,
Middle Name, First name) |
|
| Date of Birth
(Month/Day/Year) |
|
| Country of
Birth |
|
| Relationship |
|
| Applying with
you |
YesNo |
|
|
| Complete Name (Last Name,
Middle Name, First name) |
|
| Date of Birth
(Month/Day/Year) |
|
| Country of
Birth |
|
| Relationship |
|
| Applying with
you |
YesNo |
|
|
| Complete Name (Last Name,
Middle Name, First name) |
|
| Date of Birth
(Month/Day/Year) |
|
| Country of
Birth |
|
| Relationship |
|
| Applying with
you |
YesNo |
|
|
| Complete Name (Last Name,
Middle Name, First name) |
|
| Date of Birth
(Month/Day/Year) |
|
| Country of
Birth |
|
| Relationship |
|
| Applying with
you |
YesNo |
Please remember make CLEAR SINGLE SIDED photocopies of the
following, attach and return with this questionnaire:
A. Form
I-94 (front AND back)
B. Most recent nonimmigrant visa in your
passport that you used to enter the U.S.
C. Birth certificate
(also your family's, as well as your marriage certificate, if
applicable)
REMEMBER YOU
WILL BE SWEARING UNDER OATH THAT MOST IF NOT ALL, INFORMATION
PROVIDED IN THIS QUESTIONNAIRE IS TRUE AND COMPLETE!
|
| Nationality |
|
| Other names used
(for wife include names used prior
marriage) |
|
| City and Country of
Birth |
|
|
| Social Security
No. |
|
| Family Name |
|
| First Name |
|
| Date of
Birth |
|
| City of
Birth |
|
| Country of
Birth |
|
| City of
Residence |
|
| Country of
Residence |
|
|
| Father |
|
| Mother |
|
| Husband And/Or Wife
:: |
|
| Family Name (for wife,
give name prior to marriage) |
|
| First Name |
|
| Birth Date |
|
| City of
Birth |
|
| Country of
Birth |
|
| Date of
marriage |
|
| Place of
marriage |
|
|
| Former Husbands Or Wives
:: |
|
| Family Name (for wife,
give name prior to marriage) |
|
| First Name |
|
| Birth Date |
|
| City of
Birth |
|
| Country of
Birth |
|
| Date of termination of
marriage |
|
| Place of termination of
marriage |
|
|
| Applicant's
residence for last 5 years (List present address
first) |
Present Address
(Street and number, City, Province or State,
Country) |
From To |
| Address 1 |
From To |
| Address 2 |
From To |
| Address 3 |
From To |
| Address 4 |
From To |
| Address 5 |
From To |
|
| Applicant's
Employment in last 5 years (List present employer
first) |
| Present Employer (Name
& Address) |
|
| Occupation
(specify) |
From
To
|
| Name & Address
1 |
|
| Occupation
(specify) |
From
To
|
| Name & Address
2 |
|
| Occupation
(specify) |
From
To
|
| Name & Address
3 |
|
| Occupation
(specify) |
From
To
|
| Name & Address
4 |
|
| Occupation
(specify) |
From
To
|
| Name & Address
5 |
|
| Occupation
(specify) |
From
To
|
|
| Last Occupation Abroad (if
not included Above ) |
|
| Name & Address of
Employer |
|
| Occupation
(specify) |
From
To
|
|
| Last address outside the
U.S. for more than one year |
|
| Street and number, City,
Province or State, Country |
From To |
|
| Date of Form
Completion |
|