Client Questionnaire Personal (U.S.)

Your Name (Last, First, Middle)*

Other Names (Maiden, Religious, Professional, Aliases)

Sex
 Male Female

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.

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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.?
 Yes No

Passport No.

Date Issued (Mo/Day/Yr)

Date Expires (Mo/Day/Yr)

Color of Hair

Color of Eyes

Complexion

Height

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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?
 Yes No

If so, when?

Are either you or your spouse an American Indian born in Canada of at least 50 percent Native bloodline?
 Yes No

Are either you or your spouse eligible for a Native American tribal document?
 Yes No

Marital Status
 Married Widowed Divorced Separated Single

Will your spouse accompany you to the U.S.?
 Yes No

Spouse’s Name (Last, First, Middle)

Other Names (Maiden, Religious, Professional, Aliases)

Sex
 Male Female

Date of Birth (Mo/Day/Yr)

Place of Birth (City, State, Country)

Citizenship (Country)

U.S. Social Security No.

Date of Marriage

Place of marriage

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Spouse’s Former Spouse Name (1)

Country of Citizenship

Date of Divorce/Death

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Spouse’s Former Spouse Name (2)

Country of Citizenship

Date of Divorce/Death

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Spouse’s Former Spouse Name (3)

Country of Citizenship

Date of Divorce/Death

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Spouse’s Former Spouse Name (4)

Country of Citizenship

Date of Divorce/Death

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Is your spouse currently working in the U.S.?
 Yes No

If yes, does he or she have authorization to work full-time?
 Yes No

If no, does he or she wish to work in the U.S.?
 Yes No

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Were you previously married?
 Yes No

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Your First Former Spouse’s Name (Last, First, Middle)

Date of Birth (Mo/Day/Yr)

Place of Birth (City, State, Country)

Citizenship (Country)

Date of Divorce/Death

Place of Divorce

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Your Second Former Spouse’s Name (Last, First, Middle)

Date of Birth (Mo/Day/Yr)

Place of Birth (City, State, Country)

Citizenship (Country)

Date of Divorce/Death

Place of Divorce

Sibling or Child 1 Name (Last, First)

Relationship

Date of Birth (Mo/Day/Yr)

Place of Birth (City, State, Country)

Applying with you?
 Yes No

Immigration Status

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Sibling or Child 2 Name (Last, First)

Relationship

Date of Birth (Mo/Day/Yr)

Place of Birth (City, State, Country)

Applying with you?
 Yes No

Immigration Status

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Sibling or Child 3 Name (Last, First)

Relationship

Date of Birth (Mo/Day/Yr)

Place of Birth (City, State, Country)

Applying with you?
 Yes No

Immigration Status

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Sibling or Child 4 Name (Last, First)

Relationship

Date of Birth (Mo/Day/Yr)

Place of Birth (City, State, Country)

Applying with you?
 Yes No

Immigration Status

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Sibling or Child 5 Name (Last, First)

Relationship

Date of Birth (Mo/Day/Yr)

Place of Birth (City, State, Country)

Applying with you?
 Yes No

Immigration Status

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Sibling or Child 6 Name (Last, First)

Relationship

Date of Birth (Mo/Day/Yr)

Place of Birth (City, State, Country)

Applying with you?
 Yes No

Immigration Status

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.?
 Yes No

Present Address First

Present Street Address/Apt. #

Present City/State

Present Country

From (Mo/Yr)

To (Mo/Yr)

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Former Street Address/Apt. # (1)

Former City/State

Former Country

From (Mo/Yr)

To (Mo/Yr)

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Former Street Address/Apt. # (2)

Former City/State

Former Country

From (Mo/Yr)

To (Mo/Yr)

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Former Street Address/Apt. # (3)

Former City/State

Former Country

From (Mo/Yr)

To (Mo/Yr)

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Last address outside of U.S. more than one year

Last Abroad Street Address/Apt. #

Last Abroad City/State

Last Abroad Country

From (Mo/Yr)

To (Mo/Yr)

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Former Abroad Street Address/Apt. #

Former Abroad City/State

Former Abroad Country

From (Mo/Yr)

To (Mo/Yr)

(if more space is required, use Additional Message box on the bottom)

Group Name (1)

Group City/State

From (Mo/Yr)

To (Mo/Yr)

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Group Name (2)

Group City/State

From (Mo/Yr)

To (Mo/Yr)

---

Group Name (3)

Group City/State

From (Mo/Yr)

To (Mo/Yr)

---

Group Name (4)

Group City/State

From (Mo/Yr)

To (Mo/Yr)

---

Group Name (5)

Group City/State

From (Mo/Yr)

To (Mo/Yr)

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Group Name (6)

Group City/State

From (Mo/Yr)

To (Mo/Yr)

Company Name

Company Address

Type of Business

Date Company Established

IRS Tax No.

No. of Employees

Annual Income: Gross
$ 

Annual Income: Net
$ 

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Position full-time?
 Yes No

Number of Hours per Week

Wages per Week
$ 

Other Compensation?
 Yes No

Value
$ 

Company Contact

Company Telephone

Company Facsimile

Job Title

Job Duties

Location of Place of Employment

Work Schedule From

 AM PM

Work Schedule To

 AM PM

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?
 Yes No

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

From (Mo/Yr)

To (Mo/Yr)

Degree

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School Name/Address (2)

Field of Study

From (Mo/Yr)

To (Mo/Yr)

Degree

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School Name/Address (3)

Field of Study

From (Mo/Yr)

To (Mo/Yr)

Degree

---

School Name/Address (4)

Field of Study

From (Mo/Yr)

To (Mo/Yr)

Degree

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List professional licenses:

(if additional space is required, use Additional Message box on the bottom)

Present Employer

Address

From (Mo/Yr)

To (Mo/Yr)

Job Title

Job Duties

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Former Employer (1)

Address

From (Mo/Yr)

To (Mo/Yr)

Job Title

Job Duties

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Former Employer (2)

Address

From (Mo/Yr)

To (Mo/Yr)

Job Title

Job Duties

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Last Occupation Abroad:

Last Employer Abroad

Address

From (Mo/Yr)

To (Mo/Yr)

Job Title

Job Duties

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Have you ever been placed in immigration proceedings?
 Yes No

If so, which? Select all that apply.
 Exclusion Deportation Rescission Judicial Proceedings

Where:

When:

Have you ever applied for a U.S. nonimmigrant visa before?
 Yes No

If yes,

Classification:

Where:

When:

Outcome?
 Issued Refused

Nonimmigrant Visa No.:

Has your U.S. visa ever been canceled?
 Yes No

Plan to apply for immigrant visa abroad?
 Yes No

If yes, where:

Plan to adjust status in U.S.?
 Yes No

If yes, where:

1. Have you ever (in or outside the United States):
   1. Knowingly committed any crime of moral turpitude or a drug-related offense for which you have not been arrested?
       Yes No
   2. Been arrested, cited, charged, indicted, fined or imprisoned for breaking or violating any law or ordinance, excluding traffic violations?
       Yes No
   3. Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency or similar action?
       Yes No
   4. Exercised diplomatic immunity to avoid prosecution for a criminal offense?
       Yes No

      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
      

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      Date of Offense (2)
      

      Place (City/State/Country)
      

      Nature of Offense
      

      Outcome
      

      ---

      Date of Offense (3)
      

      Place (City/State/Country)
      

      Nature of Offense
      

      Outcome
      

      ---

      Date of Offense (4)
      

      Place (City/State/Country)
      

      Nature of Offense
      

      Outcome
      

2. 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?
    Yes No

   If yes, explain. (Include the names and Social Security number(s) you used)
   

3. Have you ever:
   1. Within the past 10 years been a prostitute or procured anyone for prostitution, or intend to engage in such activities in the future?
       Yes No
   2. Engaged in any unlawful commercialized vice, including but not limited to illegal gambling?
       Yes No
   3. Knowingly encouraged, induced, assisted, abetted or aided any alien to try to enter the U.S. illegally?
       Yes No
   4. Illicitly trafficked in any controlled substance or knowingly assisted, abetted or colluded in the illicit trafficking of any controlled substance?
       Yes No
4. 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?
    Yes No
5. Do you intend to engage in the U.S. in:
   1. Espionage?
       Yes No
   2. 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?
       Yes No
   3. Any activity to violate or evade any law prohibiting the export from the United States of goods, technology or sensitive information?
       Yes No
6. Have you ever been a member of, or in any way affiliated with, the Communist Party or any other totalitarian party?
    Yes No
7. 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?
    Yes No
8. 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?
    Yes No
9. 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?
    Yes No
10. 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?
     Yes No
11. Have you ever left the U.S. to avoid being drafted into the U.S. Armed Forces?
     Yes No
12. 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?
     Yes No
13. Are you now withholding custody of a U.S. citizen child outside the U.S. from a person granted custody of the child?
     Yes No
14. Do you plan to practice polygamy in the U.S.?
     Yes No

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