Immigration Questionnaire

Name:

Present Address (Outside of U.S.):

Phone Number (Abroad):

Present Address (if in U.S.):

Birthdate (MM/DD/YY):

Type of Visa (if in U.S.):

Birthplace:

Present Nationality or Citizenship:

Names and Addresses of Schools and Universities:

Name of School:

Address of School:

Field of Study:

Started (MM/DD/YY):

Graduated (MM/DD/YY):

Name of School:

Address of School:

Field of Study:

Started (MM/DD/YY):

Graduated (MM/DD/YY):

Name of School:

Address of School:

Field of Study:

Started (MM/DD/YY):

Graduated (MM/DD/YY):

List Professional Licenses (with ID Numbers):

List Work Experience:

Current Employer:

Address:

Name of Job:

Date Started (MM/DD/YY):

Kind of Business:

Describe in Detail the
Duties Performed:

Prior Employment

Name of Employer:

Address:

Name of Job:

Date Started (MM/DD/YY):

Kind of Business:

Describe in Detail the
Duties Performed:

Name of Employer:

Address:

Name of Job:

Date Started (MM/DD/YY):

Kind of Business:

Describe in Detail the
Duties Performed:

Name of Employer:

Address:

Name of Job:

Date Started (MM/DD/YY):

Kind of Business:

Describe in Detail the
Duties Performed:

E-Mail Address:

Name of Father:

Father's Place of Birth:

Father's Date of Birth (MM/DD/YY):

Deceased? Yes No Year (YYYY):

Father's Residence:

Name of Mother:

Mother's Place of Birth:

Mother's Date of Birth (MM/DD/YY):

Deceased? Yes No Year (YYYY):

Mother's Residence:

Were any of your grandparents born in the U.S.? Yes No

If so, where:

Marital Status: M W D SP S Date of Marriage (MM/DD/YY):

Number of Times Married (including this marriage):

Spouse's Name:

Spouse's Place of Birth:

Spouse's Date of Birth (MM/DD/YY):

Spouse's Citizenship:

Date/Place of Marriage:

Former Spouse's Name:

Former Spouse's Date of Birth (MM/DD/YY):

Former Spouse's Citizenship:

Date of Termination of Marriage or Death (MM/DD/YY):

Where?

List All of Your Residences for the Past 10 Years:

Address #1:

From (MM/YY):

To (MM/YY):

Address #2:

From (MM/YY):

To (MM/YY):

Address #3:

From (MM/YY):

To (MM/YY):

Last Address Outside of U.S. of
More Than One Year:

Education: High School College

Degrees Earned:

Date/Place of Last Arrival in U.S.:

Has a prior visa petition ever been filed? Yes No

If YES, then answer the following lines:

Where? When (MM/DD/YY)? Approved? Yes No

Means of Travel Into U.S.: Inspected? Yes No

Status at Entry (example: visitor, student):

Passport Number:

Passport Issue Date (MM/DD/YY):

Passport Expiration Date (MM/DD/YY):

Consulate Visa Issued:

Visa Number:

Date Visa Issued (MM/DD/YY):

Date Visa Issued (MM/DD/YY): or Indefinite: Yes No

Visa Classification:

I-94 Number:

I-94 Issue Date (MM/DD/YY: I-94 Expiration Date (MM/DD/YY:

Duration of Stay:

Name Exactly as it Appears on I-94:

List Children, Including Stepchildren:

Name:

Relationship:

Date of Birth (MM/DD/YY):

City, State of Birth:

Country of Birth:

Address (If Different):

Name:

Relationship:

Date of Birth (MM/DD/YY):

City, State of Birth:

Country of Birth:

Address (If Different):

Name:

Relationship:

Date of Birth (MM/DD/YY):

City, State of Birth:

Country of Birth:

Address (If Different):

Name:

Relationship:

Date of Birth (MM/DD/YY):

City, State of Birth:

Country of Birth:

Address (If Different):

List ALL Present/Past Membership in Groups of Any Kind: Include Group Name, Location (City/State), and Time Period (MM/YY) To (MM/YY), separating groups with semicolons (;).

Have You ever filed for Permanent Residence in the U.S.? Yes No

If yes, give date and place of filing:

Have you ever:

committed a crime?

Yes No

been arrested?

Yes No

been granted pardon?

Yes No

(include all traffic tickets)

If answered YES to any of the above, give the following information: Date (MM/DD/YY), Place (City/State/County), Nature of Offense and Outcome. Separate offenses with a semicolon (;).

Have you ever been given public assistance? Yes No

If YES, explain:

Have you ever:

Committed a crime of moral turpitude or drug-related offense for which you were not arrested?	Yes No
Been arrested, cited, charged, indicted, fined or imprisoned for breaking a law, excluding traffic violations?	Yes No
Been the recipient of an act of clemency or similar action?	Yes No
Exercized diplomatic immunity to avoid prosecution in the U.S.?	Yes No
Received public assistance in the U.S. from any source, or likely to in the future?	Yes No
Engaged in prostitution in the past 10 years, or likely to in the future?	Yes No
Engaged in unlawful commercialized vice such as illegal gambling?	Yes No
Encouraged any alien to enter the U.S. illegally?	Yes No
Trafficked in any controlled substance?	Yes No
Been in any way involved in any terrorist activity?	Yes No
Engaged in espionage or intend to once in the U.S.?	Yes No
Been a member of or affiliated with the Communist Party?	Yes No
Engaged in genocide or persecuted any person because of race, religion, national origin or political opinion?	Yes No
Been exported or excluded from the U.S.?	Yes No
Committed fraud in order to obtain entry into the U.S.?	Yes No
Left the U.S. to avoid being drafted into the U.S. Army?	Yes No
Been a J nonimmigrant visitor and not complied with the 2 year foreign residence requirement or obtained a waiver?	Yes No
Withheld custody of a U.S. citizen child from a person granted custody of the child?	Yes No
Been a polygamist or plan to practice polygamy in the U.S.?	Yes No
Claim to be a U.S. citizen?	Yes No

If answered YES to any of the above, explain fully below:

I CERTIFY THAT THE ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.

Name: Date (MM/DD/YY):

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