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Your Name (Last, First, Middle)*

Other Names (Maiden, Religious, Professional, Aliases)

Date of Birth (Mo/Day/Yr)

Place of Birth (City, State, Country)

Citizenship (Country)

Email*

Address

Telephone

Facsimile


Marital Status
 Married Widowed Divorced Separated Single

Spouse’s Name (Last, First, Middle)

Date of Birth (Mo/Day/Yr)

Place of Birth (City, State, Country)


Child 1 Name (Last, First)

Date of Birth (Mo/Day/Yr)

Place of Birth (City, State, Country)


Child 2 Name (Last, First)

Date of Birth (Mo/Day/Yr)

Place of Birth (City, State, Country)


Child 3 Name (Last, First)

Date of Birth (Mo/Day/Yr)

Place of Birth (City, State, Country)


Child 4 Name (Last, First)

Date of Birth (Mo/Day/Yr)

Place of Birth (City, State, Country)


Child 5 Name (Last, First)

Date of Birth (Mo/Day/Yr)

Place of Birth (City, State, Country)


Child 6 Name (Last, First)

Date of Birth (Mo/Day/Yr)

Place of Birth (City, State, Country)


Applicant's College/University Name (1)

From (Mo/Yr)

To (Mo/Yr)

Degree


Applicant's College/University Name (2)

From (Mo/Yr)

To (Mo/Yr)

Degree


Applicant's College/University Name (3)

From (Mo/Yr)

To (Mo/Yr)

Degree


Spouse's College/University Name (1)

From (Mo/Yr)

To (Mo/Yr)

Degree


Spouse's College/University Name (2)

From (Mo/Yr)

To (Mo/Yr)

Degree


Spouse's College/University Name (3)

From (Mo/Yr)

To (Mo/Yr)

Degree


Applicant's Post Secondary Schooling (1)

From (Mo/Yr)

To (Mo/Yr)

Degree


Applicant's Post Secondary Schooling (2)

From (Mo/Yr)

To (Mo/Yr)

Degree


Applicant's Post Secondary Schooling (3)

From (Mo/Yr)

To (Mo/Yr)

Degree


Spouse's Post Secondary Schooling (1)

From (Mo/Yr)

To (Mo/Yr)

Degree


Spouse's Post Secondary Schooling (2)

From (Mo/Yr)

To (Mo/Yr)

Degree


Spouse's Post Secondary Schooling (3)

From (Mo/Yr)

To (Mo/Yr)

Degree


If self-employed, list position.

Business Address

Type of Business

Telephone

Facsimile

Email


Present Occupation

Present Employer

Address

Telephone


List last three prior employers.

Prior Employer (1)

Address

Telephone


Prior Employer (2)

Address

Telephone


Prior Employer (3)

Address

Telephone


Do you have any U.S. citizen relatives?
 Yes No

If so, list their relationship to you and status.

Relative 1 Name (Last, First)

Relationship

Immigration Status


Relative 2 Name (Last, First)

Relationship

Immigration Status


Relative 3 Name (Last, First)

Relationship

Immigration Status


Relative 4 Name (Last, First)

Relationship

Immigration Status


Relative 5 Name (Last, First)

Relationship

Immigration Status


Relative 6 Name (Last, First)

Relationship

Immigration Status


Where were your grandparents born?


Have you ever applied for a visa to the U.S.?
 Yes No

If yes, list the type of visa:

Outcome?
 Granted Denied

Date visa was issued:


Have you ever been arrested for any crime, regardless of whether charges were filed or whether you were found innocent?
 Yes No


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.

IMPORTANT: Review all sections carefully before submitting.