We recommend you to download and use the PREVIEW FORM on right. You can also email the filled form as an attachment to: firstname.lastname@example.org.
Call us at 425-259-1807 if you have any questions.
(* required. If additional space is required, use Additional Message box on the bottom.)
Your Name (Last, First, Middle)*
Other Names (Maiden, Religious, Professional, Aliases)
Date of Birth (Mo/Day/Yr)
Place of Birth (City, State, Country)
U.S. Social Security No.
Permanent Address Abroad
Telephone in U.S.
Facsimile in U.S.
If in the U.S., complete the following:
Date of Arrival (Mo/Day/Yr)
Current Nonimmigrant Status
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.?
Date Issued (Mo/Day/Yr)
Date Expires (Mo/Day/Yr)
Color of Hair
Color of Eyes
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?
Married Widowed Divorced Separated Single
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)
Sibling or Child 1 Name (Last, First)
Applying with you?
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.?
Present Address First
Present Street Address/Apt. #
Former Street Address/Apt. # (1)
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
(if more space is required, use Additional Message box on the bottom)
Group Name (1)
Group Name (2)
Group Name (3)
Group Name (4)
Group Name (5)
Group Name (6)
Type of Business
Date Company Established
IRS Tax No.
No. of Employees
Annual Income: Gross
Annual Income: Net
Number of Hours per Week
Wages per Week
Location of Place of Employment
Work Schedule From
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
School Name/Address (1)
Field of Study
School Name/Address (2)
School Name/Address (3)
School Name/Address (4)
List professional licenses:
(if additional space is required, use Additional Message box on the bottom)
Former Employer (1)
Former Employer (2)
Last Occupation Abroad:
Last Employer Abroad
Have you ever been placed in immigration proceedings?
If so, which? Select all that apply.
Exclusion Deportation Rescission Judicial Proceedings
Have you ever applied for a U.S. nonimmigrant visa before?
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.?
If you answered YES to any of the above, give the following information:
Date of Offense (1)
Nature of Offense
Date of Offense (2)
Date of Offense (3)
Date of Offense (4)
If yes, explain. (Include the names and Social Security number(s) you used)
If you answered YES to any of the above, explain fully:
By checking the box below I certify that the information provided on this questionnaire is true and correct to the best of my knowledge.
IMPORTANT: Review all sections carefully before submitting.