I. PERSONAL INFORMATION

1. Name (Family Name, First Name, Middle Name)

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2. Have you ever used any other Name/Alias?
(If married woman, give maiden name and surname of any former spouses)

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3. Sex (Male or Female) ____________

4. Height ____________ Weight ____________ Color of Hair ____________

Color of Eyes ____________ Complexion ____________

Visible Distinguishing Marks___________________________________________

5. Place of Birth (City or Town, Province or State, Country)

____________________________________________________________________________

6. Date of Birth (Month, Day, Year)

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7. Country where your passport was issued

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8. Address in Home Country (No. & Street, Apt. No., City or Town, Province, Country)

____________________________________________________________________________

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8a. Please list the dates that you lived at the above address:

From___________________ To______________________________

9. Current Address

____________________________________________________________________________

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10. Telephone Number:
( ) _________-_____________________

Alternate Telephone No. (Your work number or the number of a friend/family member who will know where to contact you.)
( ) _________-______________________

11. Social Security Number (If None, Write "None")

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12. Profession or Occupation

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II. MARITAL STATUS

SINGLE (NEVER MARRIED) | ENGAGED | SEPARATED | WIDOWED | DIVORCED | MARRIED

IF MARRIED:

1. Name of Spouse (Family Name, First Name, Maiden Name)

____________________________________________________________________________

2. Place of Birth (Spouse) (City or Town, State or Country)

____________________________________________________________________________

3. Date of Birth (Spouse) (Month, Day, Year)

____________________________________________________________________________

4. Spouse's Passport Number ________________________

Expiration Date_______________________

Country of Issue________________________________

5. Is your Spouse a Permanent Resident? (Yes or No) ____________

If YES: Give Date (Month, Day, Year) and Place of Permanent Residence (City, State or Country)

____________________________________________________________________________

____________________________________________________________________________

What is your SPOUSE'S Alien Registration No.

____________________________________________________________________________

6. Is your SPOUSE a U.S. Citizen? (Yes or No) ____________

If YES, By Birth or By Naturalization ________________________

On (Date) ____________ At (Place) ________________________

III. FAMILY INFORMATION

1. Number of Children ____________________

FOR ALL YOUR CHILDREN:

NAME, SEX, PLACE OF BIRTH, DATE OF BIRTH, NOW LIVING AT

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

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MEMBERS OF YOUR FAMILY WHO WANT TO ENTER THE USA WITH YOU:

NAME, RELATIONSHIP

____________________________________________________________________________

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____________________________________________________________________________

____________________________________________________________________________

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IV. ADDRESSES

1. RESIDENCES LAST FIVE YEARS (LIST PRESENT ADDRESS FIRST)

(STREET & NO., APT.#, CITY, STATE, COUNTRY, FROM (MONTH/YEAR), TO (MONTH/YEAR)

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V. VISA INFORMATION

1. Have you ever applied for an Immigrant or Nonimmigrant U.S. Visa before?

No_____________ YES________________

WHERE?______________________________ WHEN?_______________________________

___________VISA WAS ISSUED

___________VISA WAS REFUSED

TYPE OF VISA?_________________________

2. Has your U.S. Visa ever been canceled?

________________NO ______________________YES

3. (a) Has anyone ever filed an Immigrant Visa petition on your behalf?
(b) Has Labor Certification for Employment in the U.S. ever been requested by you or on your behalf?
(c) Have you or anyone acting for you ever indicated to a U.S. Consular or Immigration Employee a desire to Immigrate to the U.S.?

(a) NO ________ YES ________

(b) NO ________ YES ________

(c) NO ________ YES ________

4. Are any of the following in the U.S.? (If YES, Circle Appropriate Relationship and indicate what that person is doing in the U.S., I.E., STUDYING, WORKING, ETC.)

HUSBAND/WIFE__________________

FIANCE/FIANCEE______________________

FATHER/MOTHER_________________

SON/DAUGHTER______________________

BROTHER/SISTER_________________

IF YOU ARE PRESENTLY IN THE U.S., PLEASE ANSWER THE FOLLOWING:

5. Date you last entered the U.S. (Month, Day, Year)

____________________________________________________________________________

6. Port of Entry (City, State)

____________________________________________________________________________

7. Means of Travel (Give name of Airline/Ship on which you travelled to U.S.)

____________________________________________________________________________

8. Type of Visa with which you entered: (Circle One)

B-1 | B-2 | C-1 | D-1 | E-1 | E-2 | F-1/F-2 | H-1 | H-2 | J-1/J-2 | K-1 | Other

9. Date and City where your visa was issued (Date and US Embassy/Consulate)

____________________________________________________________________________

VISA#_________________

I-94#____________________________

10. Expiration Date of Visa _______________

11. Expiration Date of Authorized Stay (I-94)__________

12. Passport Number___________________

Date your Passport was issued___________________

Date your Passport expires_______________________________

13. Are you or have you ever been lawfully admitted to the U.S. as a Permanent Resident? YES_________________ NO____________________

IF YES: What is your Alien Registration Number?__________________________________________

Name as it appears on your Alien Registration Card:________________________________

Date (Month, Day, Year) and Place (City, State) where your Alien Registration Card was issued:

____________________________________________________________________________

14. Did you Voluntarily give up your Permanent Residence in the U.S.? YES__________ NO_________

15. Was your Permanent Residence ever revoked for being outside the U.S. for more than one year? YES______________ NO____________________________

If YES, Give approximate date___________________________________

16. Have you ever been refused admission to the U.S.? YES_______________ NO________________

If YES, Please explain_______________________________________________________________

17. State dates of previous Residence or Visits to the U.S.: (DATE OF ENTRY, TYPE OF VISA, DATE OF DEPARTURE)

____________________________________________________________________________

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VI. EDUCATIONAL BACKGROUND

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VII. EMPLOYMENT HISTORY

1. Job Title ____________________________________________________

Salary ____________ Hours Per Week ______

Name of Employer

____________________________________________________________________________

Type of Business

____________________________________________________________________________

Address of Employer

____________________________________________________________________________

From_________ 19__________ to ___________ 19 ____________

Equipment, Tools, Hardware, Software, Etc. Used on Job:

____________________________________________________________________________

Job Duties

____________________________________________________________________________

____________________________________________________________________________

2. Job Title ____________________________________________________

Salary ____________ Hours Per Week ______

Name of Employer

____________________________________________________________________________

Type of Business

____________________________________________________________________________

Address of Employer

____________________________________________________________________________

From_________ 19__________ to ___________ 19 ____________

Equipment, Tools, Hardware, Software, Etc. Used on Job:

____________________________________________________________________________

Job Duties

____________________________________________________________________________

____________________________________________________________________________

3. Job Title ____________________________________________________

Salary ____________ Hours Per Week ______

Name of Employer

____________________________________________________________________________

Type of Business

____________________________________________________________________________

Address of Employer

____________________________________________________________________________

From_________ 19__________ to ___________ 19 ____________

Equipment, Tools, Hardware, Software, Etc. Used on Job:

____________________________________________________________________________

Job Duties

____________________________________________________________________________

____________________________________________________________________________

IF YOU HAVE HELD MORE THAN THREE JOBS, PLEASE PROVIDE THE REQUESTED INFORMATION ABOUT THESE JOBS ON A SEPARATE PIECE OF PAPER.

III. MISCELLANEOUS INFORMATION

A VISA MAY NOT BE ISSUED TO PERSONS WHO ARE WITHIN SPECIFIC CATEGORIES DEFINED BY LAW AS INADMISSIBLE TO THE UNITED STATES (EXCEPT WHEN A WAIVER IS OBTAINED IN ADVANCE). COMPLETE INFORMATION REGARDING THESE CATEGORIES AND WHETHER ANY MAY BE APPLICABLE TO YOU CAN BE OBTAINED FROM THIS OFFICE. GENERALLY, THEY INCLUDE PERSONS:

--Afflicted with Contagious Diseases (I.E., Tuberculosis) or who have suffered serious Mental Illness:

--Arrested, Convicted for any offense or crime even though subject of a Pardon, Amnesty, or other such legal action;

--Believed to be Narcotic Addicts or Traffickers;

--Deported from the U.S.A. within the last five years;

--Who have sought to obtain a Visa by Misrepresentation or Fraud;

--Who are or have been members of certain organizations including Communist Organizations and those Affiliated therewith;

--Who Ordered, Incited, Assisted, or Otherwise participated in the Persecution of any person because of Race, Religion, National Origin, or Political Opinion under the control, Direct or Indirect, of the Nazi Government of Germany, or of the Government of any area occupied by, or Allied with, the Nazi Government of Germany.

Do any of these appear to apply to you? __________ No __________ YES

If YES, Please attach an explanation.

USE THIS SPACE FOR ANY ADDITIONAL INFORMATION YOU MAY WISH TO ADD TO THIS QUESTIONNAIRE

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