Questionnaire - English
Your Primary Name
Other Names Used (Maiden Names or Nicknames)
Alien Number
A #
Social Security Number
(If You've Ever Had One)
SSN
I-94 Number
(If You Entered the US and Got One)
I-94 #
Date Of Entry
City Of Entry
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Date Of Birth
Address
Street Address
City, State & Zip
Country
Email Address
Email Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Nationality
Nationality
Country and City of Birth
Country and City of Birth
Information about your children and step-children - please list ALL children regardless of their age, if they are married or unmarried, were born inside or outside of the USA, even list children who are deceased. This includes current step-children and legally adopted children.
Name
Date of Birth
Country of Birth
Gender
Information About Your Current Marriage
Date of Marriage
Place of Marriage
Spouse's Date of Birth
Spouse's Place of Birth
Information About Your Prior Marriages
Most Recent Previous Marriage
Prior spouse’s FULL name:
Prior Spouse's Date of Birth
Date of Marriage
Place of Marriage
Date of Divorce
Place of Divorce
Prior Previous Marriage
2. Prior spouse’s FULL name:
Prior Spouse's Date of Birth
Date of Marriage
Place of Marriage
Date of Divorce
Place of Divorce
Prior Previous Marriage
2. Prior spouse’s FULL name:
Prior Spouse's Date of Birth
Date of Marriage
Place of Marriage
Date of Divorce
Place of Divorce
Places Where You Have Lived For The Past Five Years
(Starting with the most recent)
Street Address
City, State & Zip
Country
From (Month/Year)
To (Month/Year)
Previous Address
Street Address
City, State & Zip
Country
From (Month/Year)
To (Month/Year)
Previous Address
Street Address
City, State & Zip
Country
From (Month/Year)
To (Month/Year)
Last Foreign Address (i.e. Outside the U.S. of more than one year)
Address
Dates Lived There
From (Month/Year)
To (Month/Year)
Places Where You Have Worked For the Past 5 Years
(Starting with the most recent)
Employer Name
Job Title (Occupation)
Employer Address
City, State & Zip
Country
From (Month/Year)
To (Month/Year)
Did you fill out an I-9?
yes
no
If Yes, did you claim yourself as a U.S. Citizen?
yes
no
Previous Employer #2
Employer Name
Job Title (Occupation)
Employer Address
City, State & Zip
Country
From (Month/Year)
To (Month/Year)
Did you fill out an I-9?
yes
no
If Yes, did you claim yourself as a U.S. Citizen?
yes
no
Previous Employer #3
Employer Name
Job Title (Occupation)
Employer Address
City, State & Zip
Country
From (Month/Year)
To (Month/Year)
Did you fill out an I-9?
yes
no
If Yes, did you claim yourself as a U.S. Citizen?
yes
no
Last FOREIGN Employer
Last Foreign employer (eg. if you worked in Mexico before you came to America,
we need this information here, even if you were self employed)
Employer Name
Job Title (Occupation)
Employer Address
From (Month/Year)
To (Month/Year)
Information About Your Father
Your Father's Primary Name
Father's Date Of Birth
Father's Country and City of Birth
Country and City of Birth
Father's Current Country and City of Residence
Current Country and City of Residence
Information About Your Mother
Your Mother's Primary Name
Mother's Date Of Birth
Mother's Country and City of Birth
Country and City of Birth
Mother's Current Country and City of Residence
Current Country and City of Residence
Please Answer The Following Questions
1. Have you EVER been arrested, cited, charged, fined, indicted, or imprisoned for breaking or violating ANY law or ordinance, even if the charge or citation was dismissed, and even if the charge or citation was later expunged?
yes
no
If YES, Please explain:
2. Have you EVER been caught at the border OR deported from the United States?
yes
no
If YES, Please explain:
3. Have you EVER been denied a visa?
yes
no
If YES, Please explain:
4. Have you EVER visited a US Embassy or US Consulate before?
yes
no
If YES, Please explain:
5. When filling out paperwork for an employer, have you ever checked the Resident or U.S. Citizen box?
yes
no
If YES, Please explain:
6. Have you ever used documents that belonged to someone else?
yes
no
If YES, Please explain:
7. Have you ever served on a jury, or been called to serve jury duty?
yes
no
8. Have you ever voted in the United States?
yes
no
FOR MARRIAGE CASES
Please be advised that under U.S. Law (8 U.S.C. § 1325), if you have knowingly entered into your marriage in order to evade any provision of the immigration asw, you can be put in jail for up to 5 years, or you can be fined up to $250,000, or both.
In addition, under U.S. Law (18 U.S.C. § 101), if you willingly and knowingly lie, make a false statement, or make up false facts which are material to your immigration case, you can be put in jail for up to 5 years, or you can be fined up to $10,000, or both. Please check the box below AND type your initials in the box below to show your understanding of these laws.
I understand
My Initials
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