We recommend you to download and use the PREVIEW FORM on right. You can also email the filled form as an attachment to: [email protected]. Call us at 425-259-1807 if you have any questions.
(* required. If additional space is required, use Additional Message box on the bottom.)
I. INFORMATION REGARDING APPLICANT
Your Name (Last, First, Middle)*
Other Names (Maiden, Religious, Professional, Aliases)
Sex
MaleFemale
Date of Birth (Mo/Day/Yr)
Place of Birth (City, State, Country)
Citizenship (Country)
U.S. Social Security No.
Email*
Permanent Address Abroad
Telephone Abroad
Facsimile Abroad
U.S. Address
Telephone in U.S.
Facsimile in U.S.
If in the U.S., complete the following:
Date of Arrival (Mo/Day/Yr)
I-94 No.
Current Nonimmigrant Status
Expires (Mo/Day/Yr)
Place where Last Entered U.S.
Means of Travel into U.S.
Did you talk with a Border or Pre-Flight Inspector on entry into U.S.?
YesNo
Passport No.
Date Issued (Mo/Day/Yr)
Date Expires (Mo/Day/Yr)
Color of Hair
Color of Eyes
Complexion
Height
Marks of Identification
Father’s Name (Last, First)
Father's Date of Birth (Mo/Day/Yr)
Father's Place of Birth (City, Country)
Father's Residence (City, Country)
Mother’s Name (Last, First)
Mother's Date of Birth (Mo/Day/Yr)
Mother's Place of Birth (City, Country)
Mother's Residence (City, Country)
Were any of your or your spouse’s grandparents born in the United States?
If so, when?
Are either you or your spouse an American Indian born in Canada of at least 50 percent Native bloodline?
Are either you or your spouse eligible for a Native American tribal document?
II. MARITAL INFORMATION
Marital Status
MarriedWidowedDivorcedSeparatedSingle
Will your spouse accompany you to the U.S.?
Spouse’s Name (Last, First, Middle)
Date of Marriage
Place of marriage
Spouse’s Former Spouse Name (1)
Country of Citizenship
Date of Divorce/Death
Spouse’s Former Spouse Name (2)
Spouse’s Former Spouse Name (3)
Spouse’s Former Spouse Name (4)
Is your spouse currently working in the U.S.?
If yes, does he or she have authorization to work full-time?
If no, does he or she wish to work in the U.S.?
Were you previously married?
Your First Former Spouse’s Name (Last, First, Middle)
Place of Divorce
Your Second Former Spouse’s Name (Last, First, Middle)
III. LIST PRESENT BROTHERS, SISTERS AND CHILDREN, INCLUDING STEPCHILDREN
Sibling or Child 1 Name (Last, First)
Relationship
Applying with you?
Immigration Status
Sibling or Child 2 Name (Last, First)
Sibling or Child 3 Name (Last, First)
Sibling or Child 4 Name (Last, First)
Sibling or Child 5 Name (Last, First)
Sibling or Child 6 Name (Last, First)
Do you have any children who are within four years of the age of 21 who may eventually want to live permanently in the U.S.?
IV. RESIDENCES LAST FIVE YEARS
Present Address First
Present Street Address/Apt. #
Present City/State
Present Country
From (Mo/Yr)
To (Mo/Yr)
Former Street Address/Apt. # (1)
Former City/State
Former Country
Former Street Address/Apt. # (2)
Former Street Address/Apt. # (3)
Last address outside of U.S. more than one year
Last Abroad Street Address/Apt. #
Last Abroad City/State
Last Abroad Country
Former Abroad Street Address/Apt. #
Former Abroad City/State
Former Abroad Country
V. PRESENT/PAST MEMBERSHIP IN GROUPS OF ANY KIND, INCLUDING MILITARY, SINCE YOUR 16th BIRTHDAY
(if more space is required, use Additional Message box on the bottom)
Group Name (1)
Group City/State
Group Name (2)
Group Name (3)
Group Name (4)
Group Name (5)
Group Name (6)
VI. INFORMATION REGARDING U.S. EMPLOYER
Company Name
Company Address
Type of Business
Date Company Established
IRS Tax No.
No. of Employees
Annual Income: Gross
$
Annual Income: Net
Position full-time?
Number of Hours per Week
Wages per Week
Other Compensation?
Value
Company Contact
Company Telephone
Company Facsimile
VII. POSITION OFFERED IN THE U.S.
Job Title
Job Duties
Location of Place of Employment
Work Schedule From
AMPM
Work Schedule To
Name of Labor Union
Minimum Education/Degree Required to Perform the Job Duties:
Field of Study:
Do other persons with your job have this education/degree?
Special requirements/skills needed to perform the position (i.e., knowledge of certain types of computer software, foreign language, etc.):
Minimum Years of Experience Required to Perform the Job Duties:
Title of Immediate Supervisor
Number of People You will Supervise
VIII. APPLICANT’S EDUCATION
School Name/Address (1)
Field of Study
Degree
School Name/Address (2)
School Name/Address (3)
School Name/Address (4)
List professional licenses:
IX. APPLICANT’S PRIOR WORK EXPERIENCE
(if additional space is required, use Additional Message box on the bottom)
Present Employer
Address
Former Employer (1)
Former Employer (2)
Last Occupation Abroad:
Last Employer Abroad
X. IMMIGRATION-RELATED QUESTIONS
Have you ever been placed in immigration proceedings?
If so, which? Select all that apply.
ExclusionDeportationRescissionJudicial Proceedings
Where:
When:
Have you ever applied for a U.S. nonimmigrant visa before?
If yes,
Classification:
Outcome?
IssuedRefused
Nonimmigrant Visa No.:
Has your U.S. visa ever been canceled?
Plan to apply for immigrant visa abroad?
If yes, where:
Plan to adjust status in U.S.?
XI. GROUNDS OF EXCLUSION
Have you ever (in or outside the United States):
Knowingly committed any crime of moral turpitude or a drug-related offense for which you have not been arrested?
Been arrested, cited, charged, indicted, fined or imprisoned for breaking or violating any law or ordinance, excluding traffic violations?
Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency or similar action?
Exercised diplomatic immunity to avoid prosecution for a criminal offense?
If you answered YES to any of the above, give the following information:
Date of Offense (1)
Place (City/State/Country)
Nature of Offense
Outcome
Date of Offense (2)
Date of Offense (3)
Date of Offense (4)
Have you ever received public assistance in the U.S. from any source, including the U.S. Government or any state, county, city or municipality (other than emergency medical treatment), or are you likely to receive public assistance in the future?
If yes, explain. (Include the names and Social Security number(s) you used)
Have you ever:
Within the past 10 years been a prostitute or procured anyone for prostitution, or intend to engage in such activities in the future?
Engaged in any unlawful commercialized vice, including but not limited to illegal gambling?
Knowingly encouraged, induced, assisted, abetted or aided any alien to try to enter the U.S. illegally?
Illicitly trafficked in any controlled substance or knowingly assisted, abetted or colluded in the illicit trafficking of any controlled substance?
Have you ever engaged in, conspired to engage in, or do you intend to engage in, or have you ever solicited membership or funds for, or have you through any means ever assisted or provided any type of material support to, any person or organization that has ever engaged or conspired to engage in sabotage, kidnapping, political assassination, hijacking or any other form of terrorist activity?
Do you intend to engage in the U.S. in:
Espionage?
Any activity a purpose of which is opposition to, or the control or overthrow of, the Government of the United States, by force, violence or other unlawful means?
Any activity to violate or evade any law prohibiting the export from the United States of goods, technology or sensitive information?
Have you ever been a member of, or in any way affiliated with, the Communist Party or any other totalitarian party?
Did you, during the period March 23, 1933 to May 8, 1945, in association with either the Nazi Government of Germany or any organization or government associated or allied with the Nazi Government of Germany, ever order, incite, assist or otherwise participate in the persecution of any person because of race, religion, national origin or political opinion?
Have you ever engaged in genocide, or otherwise ordered, incited, assisted or otherwise participated in the killing of any person because of race, religion, nationality, ethnic origin, or political opinion?
Have you ever been deported from the U.S., or removed from the U.S. at government expense, excluded within the past year, or are you now in exclusion or deportation proceedings?
Are you under a final order of civil penalty for violating section 274C of the Immigration Act for use of fraudulent documents, or have you, by fraud or willful misrepresentation of a material fact, ever sought to procure, or procured, a visa, other documentation, entry into the U.S., or any other immigration benefit?
Have you ever left the U.S. to avoid being drafted into the U.S. Armed Forces?
Have you ever been a J nonimmigrant exchange visitor who was subject to the two-year foreign residence requirement and not yet complied with that requirement or obtained a waiver?
Are you now withholding custody of a U.S. citizen child outside the U.S. from a person granted custody of the child?
Do you plan to practice polygamy in the U.S.?
If you answered YES to any of the above, explain fully:
Additional Message
By checking the box below I certify that the information provided on this questionnaire is true and correct to the best of my knowledge.
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IMPORTANT: Review all sections carefully before submitting.
