1.

Information about your father:

Last name

First name

Date, city and country of birth

City and country of residence

2.

Information about your mother:

Maiden name

First name

Date, city and country of birth

City and country of residence

3.

Your residence for the last five years. List present address first.

Street and Number

City

State

Country

From

(mo./yr)

To

(mo./yr)

4.

Last residence outside the U.S. for more than one year.

Street and Number

City

State

Country

From

(mo./yr)

To

(mo./yr)

5.

Employment for the last five years. List present employment first.

Name of Employer, Street and Number

City

State

Country

Occupation

From

(mo./yr)

To

(mo./yr)

6.

Last occupation abroad if not shown above.

Name of Employer, Street and Number

City

State

Country

Occupation

From

(mo./yr)

To

(mo./yr)

7.

Date of last arrival:

8.

No. on I-94 card:

9.

Place of last entry in the U.S.:

10.

City and country where visa was issued:

12.

Have you ever been in the U.S. on a visa?

If yes, please list the dates (day-month-year) you were in U.S.:

13.

Have you ever before applied for employment authorization from INS?

If yes, which INS office?

Date(s) of application:

Granted or denied?

Please provide copies, front and back, of your work authorization card.

14.

Information about your spouse:

Last name (for wife, give maiden name)

First name

Date and place of marriage

Applying with you?

Current Status?

15.

Your former husbands or wives (if none, so state)

Last name (for wife, give maiden name)

First name

Date of birth

City and country of birth

Date and place of marriage

Date and place of termination of marriage

16.

List all of your children:

Child #1

Child #2

Child #3

Last name

First name

Middle name

Male or Female?

Date of birth

Place of birth

Country of Citizenship

A# (if any)

Social Security # or T.I.N.:

Applying with you?

17.

List your present or past membership in or affiliation with every political association, fund foundation, party, club, society, or similar group in the United States or in any other place since your 16th birthday. Include any military service in the past. If none, write “none.” Include the name of the organization, location, dates of membership from and to, and the nature of the organization. If additional space is needed, use separate paper.

22.

Date of intended departure:

23.

Expected length of trip:

24.

Purpose of trip:

1.

Have you ever been issued a U.S. visa? If yes, when, where, and type: _____________

Yes

No

2.

Has your visa ever been refused a U.S visa? If yes, when, where and type: ___________

Yes

No

3.

Names and Relationships of Persons Traveling with you: ___________

4.

Has your U.S. visa ever been cancelled or revoked?

Yes

No

5.

Has anyone ever filed an Immigrant Petition (Form I-140 employment or Form I-130 relative) on your behalf?

Yes

No

6.

Are any of the following persons in the US in the US or have US permanent residency or citizenship status:

a) Husband/wife?

Yes

No

b) Fiancée/Fiancé?

Yes

No

c) Father/Mother?

Yes

No

d) Brother/Sister?

e) Son/Daughter?

Yes

Yes

No

No

7.

Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty, or other similar legal action? Have you ever unlawfully distributed or sold a controlled substance (drug) or been a prostitute or procurer for prostitutes?

Yes

No

8.

 Have you ever been refused admission to the U.S. or been the subject of a deportation hearing or sought to obtain or assist others to obtain a visa entry into the U.S., or any other U.S. immigration benefit by fraud or willful misrepresentation or other unlawful means. Have you attended a U.S. public elementary school on student (F) status or a public secondary school after November 30, 1996 without reimbursing the school?

Yes

No

9.

Do you seek to enter the U.S. to engage in export control violations, subversive or terrorist activities, or any other unlawful purpose? Are you a member or representative of a terrorist organization as currently designated by the U.S. Secretary of State? Have you ever participated in persecutions directed by the Nazi government of Germany; or have you ever participated in genocide?

Yes

No

10.

Have you ever violated the terms of a U.S. visa or been unlawfully present in, or deported from the United States?

Yes

No

11.

Have you ever withheld custody of a U.S. citizen child outside the U.S. from a person granted legal custody by a U.S. court, voted in the U.S. in violation of any law or regulation, or renounced U.S. citizenship for the purpose of avoiding taxation?

Yes

No

12.

Have you ever been afflicted with a communicable disease of public health significance or a dangerous physical or mental disorder, or ever been a drug abuser or addict?

Yes

No

13.

Have you ever been a J nonimmigrant exchange visitor who was subject to the 2 year foreign residence requirement and not yet complied with that requirement or obtained a waiver?

Yes

No