SPECIAL REGISTRATION APPLICANT QUESTIONNAIRE
1. My name is:
Family/Last Name First Name Middle Name
2. My present address is:
Number and Street and Apt. No.:
City: State/Province:
Zip/Postal Code: Country:
3. My phone/fax numbers are (and I have checked the box next to the number at which I prefer to be contacted):
Home:
Work:
Cell:
Fax:
4. My e-mail address(es) is (are):
5. I prefer do not prefer to be contacted by e-mail.
6. My place of birth is:
City: State/Province: Country:
7. My date of birth is (month/day/year):
8. My country of citizenship is:
9. I am Male Female.
10. I am Married Single (never married) Divorced Widowed.
11. Other names, including maiden name, that I have used are (attach evidence of legal name change):
12. Date (month/day/year) and place (city/state/country) of my present marriage (if married):
13. My social security number is (if none, so state):
14. My Alien Registration Number is (if none, so state):
15. My passport information is:
Number:
Issuance date (month/day/year):
Expiry date (month/day/year):
Country of issuance:
16. In the last ten (10) years, I have entered the following countries:
Country: Year(s) of visit:
Country: Year(s) of visit:
Country: Year(s) of visit:
Country: Year(s) of visit:
Country: Year(s) of visit:
Country: Year(s) of visit:
Country: Year(s) of visit:
Country: Year(s) of visit:
Country: Year(s) of visit:
Country: Year(s) of visit:
17. The following countries have issued me a passport
Country of issuance:
Passport Number:
Issuance date (month/day/year):
Expiry date (month/day/year):
Country of issuance:
Passport Number:
Issuance date (month/day/year):
Expiry date (month/day/year):
18. I have lost a passport before or had a passport stolen before:
No
Yes – (a) Date of loss (month/day/year):
Place of loss (city, country):
Manner of loss (explain):
(b) Date of loss (month/day/year):
Place of loss (city, country):
Manner of loss (explain):
19. I have been issued a U.S. visa before:
No
Yes – (a) Type of visa:
Issuance date (month/date/year):
Place of issue (city, country):
(b) Type of visa:
Issuance date (month/date/year):
Place of issue (city, country):
(c) Type of visa:
Issuance date (month/date/year):
Place of issue (city, country):
(d) Type of visa:
Issuance date (month/date/year):
Place of issue (city, country):
(e) Type of visa:
Issuance date (month/date/year):
Place of issue (city, country):
20. I have been refused a U.S. visa before:
No
Yes – (a) Type of visa:
Refusal date (month/date/year):
Place of refusal (city, country):
(b) Type of visa:
Refusal date (month/date/year):
Place of refusal (city, country):
(c) Type of visa:
Refusal date (month/date/year):
Place of refusal (city, country):
(d) Type of visa:
Refusal date (month/date/year):
Place of refusal (city, country):
(e) Type of visa:
Refusal date (month/date/year):
Place of refusal (city, country):
21. My U.S. visa has been cancelled or revoked before:
No
Yes – (a) Type of visa:
Cancellation/revocation date (month/date/year):
Place of cancellation/revocation (city, country):
(b) Type of visa:
Cancellation/revocation date (month/date/year):
Place of cancellation/revocation (city, country):
(c) Type of visa:
Cancellation/revocation date (month/date/year):
Place of cancellation/revocation (city, country):
(d) Type of visa:
Cancellation/revocation date (month/date/year):
Place of cancellation/revocation (city, country):
(e) Type of visa:
Cancellation/revocation date (month/date/year):
Place of cancellation/revocation (city, country):
22. An immigrant visa petition has been filed on my behalf:
No
Yes – Type of petition:
Name of Petitioner:
Relationship of Petitioner to me:
Petitioner’s address (No. and Street and Apt. No.):
City: State/Province:
Zip/Postal Code: Country:
Date petition was filed (month/day/year):
CIS office where application was filed (city, state):
Receipt number (if available):
The petition is/was:
Pending
Denied on (Month/Day/Year)
Approved on (Month/Day/Year)
Abandoned on (Month/Day/Year)
Other:
23. The following persons are in the U.S., or they have U.S. legal permanent residence or U.S. citizenship. [Mark YES or NO and indicate that person’s status in the U.S. (i.e., U.S. legal permanent resident, U.S. citizen, F-1 student, H-1B worker, B-2 visitor, etc.).]
No Yes Husband/Wife
No Yes Father/Mother
No Yes Fiancé/Fiancée
No Yes Son/Daughter
No Yes Brother/Sister
24. My immigration status in the U.S. is:
I am in nonimmigrant visa status in the U.S. – information about my last entry into the U.S.:
Visa category used at entry: Current visa status:
Form I-94/I-95 Number:
Date of last arrival (month/day/year):
Place of last arrival (city/state):
My authorized stay, as shown on Form I-94/I-95, expires/expired on:
I was was not inspected/interviewed by a U.S. Immigration Officer.
Nonimmigrant visa number:
Consulate where visa was issued:
Date visa was issued (month/day/year):
I am a lawful permanent resident of the U.S. – information about my LPR status:
Resident since (month/day/year):
Permanent Resident Card expires on (month/day/year):
Category (e.g., IR6, CR6, E16, E36, etc.):
Consulate where Immigrant Visa was issued or CIS office where status was Adjusted (city, state/country)
Since I was granted permanent residence, I have filed Form I-407, Abandonment by Alien of Status as Lawful Permanent Resident or otherwise been judged to have abandoned my status: No Yes
I have applied for asylum in the U.S. – information about my asylum application:
Asylum application filed on (month/day/year):
CIS office where application was filed (city, state):
Date application was filed (month/day/year):
Receipt number (if available):
I was interviewed on (month/day/year) in (city, state)
The application is/was:
Pending
Denied on (Month/Day/Year)
Approved on (Month/Day/Year)
Abandoned on (Month/Day/Year)
Other:
25. I have been under immigration proceedings:
No
Yes, at on
City and State (Month/Day/Year)
and it was for this type of proceeding:
Exclusion
Deportation
Rescission
Judicial proceedings
26. I have previously applied for permanent resident status in the U.S.:
No
Yes, at on
City and State (Month/Day/Year)
and the application is/was:
Pending
Denied on (Month/Day/Year)
Approved on (Month/Day/Year)
Abandoned on (Month/Day/Year)
Other:
27. Information about my current spouse and all my children (including children born of prior marriages or relationships or who are now deceased):
(a) Full name (maiden last name/first/middle):
Relationship: Husband / Wife Date of birth (month/day/year):
Country of birth: Alien registration number:
Address Number and Street and Apt. No.:
City: State/Province:
Zip/Postal Code: Country:
Telephone No.: Date (month/day/year) of marriage:
Place (city/state/country) of marriage:
(b) Full name (last/first/middle):
Relationship: Date of birth (month/day/year):
Country of birth: Alien registration number:
Address Number and Street and Apt. No.:
City: State/Province:
Zip/Postal Code: Country:
Telephone No.:
(c) Full name (last/first/middle):
Relationship: Date of birth (month/day/year):
Country of birth: Alien registration number:
Address Number and Street and Apt. No.:
City: State/Province:
Zip/Postal Code: Country:
Telephone No.:
(d) Full name (last/first/middle):
Relationship: Date of birth (month/day/year):
Country of birth: Alien registration number:
Address Number and Street and Apt. No.:
City: State/Province:
Zip/Postal Code: Country:
Telephone No.:
(e) Full name (last/first/middle):
Relationship: Date of birth (month/day/year):
Country of birth: Alien registration number:
Address Number and Street and Apt. No.:
City: State/Province:
Zip/Postal Code: Country:
Telephone No.:
28. My last address abroad was:
Number and Street and Apt. No.:
City: State/Province:
Postal Code: Country:
Telephone No.:
29. The last address at which I lived together with my current spouse was/is:
Number and Street and Apt. No.:
City: State/Province:
Zip/Postal Code: Country:
Telephone No.:
30. Information about my father:
Name:
Family/Last Name First Name Middle Name
Date of birth (month/day/year):
City and country of birth:
Address Number and Street and Apt. No.:
City: State/Province:
Zip/Postal Code: Country:
Telephone No.:
31. Information about my mother:
Name:
Maiden Family/Last Name First Name Middle Name
Date of birth (month/day/year):
City and country of birth:
Address Number and Street and Apt. No.:
City: State/Province:
Zip/Postal Code: Country:
Telephone No.:
32. Information about my former husbands/wives:
(a) Name:
Family/Last Name (for former wife, give maiden name) First Name Middle Name
Date of birth (month/day/year):
City and country of birth:
City and country of present residence (if deceased, so indicate):
Address Number and Street and Apt. No.:
City: State/Province:
Zip/Postal Code: Country:
Telephone No.:
Date (month/day/year) of marriage:
Place (city/state/country) of marriage:
Date (month/day/year) of termination of marriage:
Place (city/state/country) of termination of marriage:
(b) Name:
Family/Last Name (for former wife, give maiden name) First Name Middle Name
Date of birth (month/day/year):
City and country of birth:
City and country of present residence (if deceased, so indicate):
Address Number and Street and Apt. No.:
City: State/Province:
Zip/Postal Code: Country:
Telephone No.:
Date (month/day/year) of marriage:
Place (city/state/country) of marriage:
Date (month/day/year) of termination of marriage:
Place (city/state/country) of termination of marriage:
33. Information about my brothers and sisters:
(a) Full name (maiden last name/first/middle):
Relationship: Date of birth (month/day/year):
Country of birth: Alien registration number:
Address Number and Street and Apt. No.:
City: State/Province:
Zip/Postal Code: Country:
Telephone No.:
(b) Full name (maiden last name/first/middle):
Relationship: Date of birth (month/day/year):
Country of birth: Alien registration number:
Address Number and Street and Apt. No.:
City: State/Province:
Zip/Postal Code: Country:
Telephone No.:
(c) Full name (maiden last name/first/middle):
Relationship: Date of birth (month/day/year):
Country of birth: Alien registration number:
Address Number and Street and Apt. No.:
City: State/Province:
Zip/Postal Code: Country:
Telephone No.:
(d) Full name (maiden last name/first/middle):
Relationship: Date of birth (month/day/year):
Country of birth: Alien registration number:
Address Number and Street and Apt. No.:
City: State/Province:
Zip/Postal Code: Country:
Telephone No.:
(e) Full name (maiden last name/first/middle):
Relationship: Date of birth (month/day/year):
Country of birth: Alien registration number:
Address Number and Street and Apt. No.:
City: State/Province:
Zip/Postal Code: Country:
Telephone No.:
34. Two contacts (not including my immediate family members or other relatives) in my native country who can verify information about me:
(a) Full name (maiden last name/first/middle):
Address Number and Street and Apt. No.:
City: State/Province:
Zip/Postal Code: Country:
Telephone No.:
(b) Full name (maiden last name/first/middle):
Address Number and Street and Apt. No.:
City: State/Province:
Zip/Postal Code: Country:
Telephone No.:
35. Information about my residences for the last ten years, starting with my present address:
(a) Number and Street and Apt. No.:
City: State/Province:
Country: From: To: PRESENT
Month/Year Month/Year
(b) Number and Street and Apt. No.:
City: State/Province:
Country: From: To:
Month/Year Month/Year
(c) Number and Street and Apt. No.:
City: State/Province:
Country: From: To:
Month/Year Month/Year
(d) Number and Street and Apt. No.:
City: State/Province:
Country: From: To:
Month/Year Month/Year
(e) Number and Street and Apt. No.:
City: State/Province:
Country: From: To:
Month/Year Month/Year
(f) Number and Street and Apt. No.:
City: State/Province:
Country: From: To:
Month/Year Month/Year
(g) Number and Street and Apt. No.:
City: State/Province:
Country: From: To:
Month/Year Month/Year
(h) Number and Street and Apt. No.:
City: State/Province:
Country: From: To:
Month/Year Month/Year
(i) Number and Street and Apt. No.:
City: State/Province:
Country: From: To:
Month/Year Month/Year
(j) Number and Street and Apt. No.:
City: State/Province:
Country: From: To:
Month/Year Month/Year
36. Information about my last address outside the United States of more than one year:
Number and Street and Apt. No.:
City: State/Province:
Country: From: To:
Month/Year Month/Year
Telephone No.:
37. Information about all educational institutions I attended or have attended, including vocational institutions but not elementary schools:
(a) School Name:
Number and Street and Apt. No.:
City: State/Province:
Country: Course of Study:
Telephone No.: From: To:
Month/Year Month/Year
(b) School Name:
Number and Street and Apt. No.:
City: State/Province:
Country: Course of Study:
Telephone No.: From: To:
Month/Year Month/Year
(c) School Name:
Number and Street and Apt. No.:
City: State/Province:
Country: Course of Study:
Telephone No.: From: To:
Month/Year Month/Year
(d) School Name:
Number and Street and Apt. No.:
City: State/Province:
Country: Course of Study:
Telephone No.: From: To:
Month/Year Month/Year
(e) School Name:
Number and Street and Apt. No.:
City: State/Province:
Country: Course of Study:
Telephone No.: From: To:
Month/Year Month/Year
38. Information about my employment history for the last four employers, starting with my present employer (if none, so state):
(a) Employer Name: Job Title:
Number and Street and Apt. No.:
City: State/Province:
Country: From: To: PRESENT
Month/Year Month/Year
Telephone No.: Description of my job duties:
(b) Employer Name: Job Title:
Number and Street and Apt. No.:
City: State/Province:
Country: From: To:
Month/Year Month/Year
Telephone No.: Description of my job duties:
(c) Employer Name: Job Title:
Number and Street and Apt. No.:
City: State/Province:
Country: From: To:
Month/Year Month/Year
Telephone No.: Description of my job duties:
(d) Employer Name: Job Title:
Number and Street and Apt. No.:
City: State/Province:
Country: From: To:
Month/Year Month/Year
Telephone No.: Description of my job duties:
39. My present and past membership in or affiliation with every political, professional, social and charitable organizations, associations, funds, foundations, parties, clubs, societies, or similar groups in the United States or in other places since my 16th birthday (if none, so state):
Name of organization Location (city/state) Dates of membership Nature of organization
40. Please answer the following questions. (If your answer is “Yes” on any one of these questions, explain on a separate piece of paper. Answering “Yes” does not necessarily mean that you are not entitled to register for permanent residence or adjust status.)
(1) Have you ever, in or outside the U.S.:
a. knowingly committed any crime of moral turpitude or a drug related offense for which you have not been arrested? Yes No
b. been arrested, cited, charged, indicted, fined, or imprisoned for breaking or violating any law or ordinance, excluding minor traffic violations? Yes No
c. been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency or similar action? Yes No
d. exercised diplomatic immunity to avoid prosecution for a criminal offense in the U.S.? Yes No
(2) Have you 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
(3) Have you ever:
a. 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
b. engaged in any unlawful commercialized vice, including, but not limited to, illegal gambling? Yes No
c. knowingly encouraged, induced, assisted, abetted or aided any alien to try to enter the U.S. illegally? Yes No
d. 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:
a. espionage? Yes No
b. 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
c. 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
(15) 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
(16) 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? Yes No
(17) Have you ever violated the terms of a U.S. visa, or been unlawfully present in, or deported from, the United States? Yes No
(18) Have you ever voted in the United States in violation of any law or regulation? Yes No
(19) Have you ever renounced U.S. citizenship for the purpose of avoiding taxation? Yes No
(20) 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
(21) Do you have any specialized skills or training, including firearms, explosives, nuclear, biological, or chemical experience? Yes No
(22) Have you ever performed military service? Yes No
If YES, give name of country, branch of service, rank/position, military specialty, and dates of service:
(23) Have you ever been in an armed conflict, either as a participant or victim? Yes No
# # #
If you would like further information about specific case scenarios or situations, please call our office or email us at ckuck@immigration.net to speak to one of experienced immigration attorneys.
DISCLAIMER: The confidential information provided in this memorandum is for information purposes only and is not intended to be legal advice. This information is not intended to create an attorney-client or other relationship between Kuck Immigration Partners LLC and the recipient. The reader should consult with an immigration attorney before acting in reliance on any such information.
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