Main Questionnaire

About You (The Applicant)

1. Full name:

First Middle Last

2. All other names used (maiden names, names by previous marriages)

First name

Middle name

Last name

3. Gender as it appears on your passport

Male

Female

X

4. Date of birth

4a. Have you ever used any other date of birth?

Yes

No

4b. Please provide all other dates of birth (mm/dd/yyyy)

5. All other dates used as birth dates:

6. City and country of birth

7. Citizenship/nationality

8. Are you Hispanic or Latino?

Hispanic or Latino

Not Hispanic or Latino

9. Race

Asian

Black or African American

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

White

Height

Units:

Weight

Units:

12. Eye color

13. Hair Color

14. Alien Registration Number (if applicable)

14a. Have you ever used, or been assigned, any other A-Number?

Yes

No

14b. Please provide those additional A-Numbers

15. USCIS Online Account Number (if applicable)

16. US Social Security Number (if applicable)

17. Phone Number(s)

18. Email

About Your Parents

1. Father’s name

First Middle Last

2. Father’s name at birth (if different than above)

First Middle Last

3. Father’s date of birth

4. Father’s city of birth

5. Father’s country of birth

6. Father is deceased:

Yes

7. Father’s current city of residence

8. Father’s current country of residence

1. Mother’s current name

First Middle Last

2. Mother’s name at birth (if different from above)

First Middle Last

3. Mother’s date of birth

4. Mother’s city of birth

5. Mother’s country of birth

6. Mother is deceased:

Yes

7. Mother’s current city of residence

8. Mother’s current country of residence

About Where You've Lived

Current foreign address:

Street Address Apt/Ste/Flr Unit# City Province / State / Region Postal Code Country

List your residences for the last five years.

There can be no time gaps in your residence history. If you have any questions, please ask and we can help clarify/advise.

Current address

Street Address Apt/Ste/Flr Unit# City State / Province / Region ZIP / Postal Code Country

Date moved to this address:

Your address before your current one:

Street Address Apt/Ste/Flr Unit# City State / Province / Region ZIP / Postal Code Country

Dates at this address: From:

To:

Your address before that (if any):

Street Address Apt/Ste/Flr Unit# City State / Province / Region ZIP / Postal Code Country

Dates at this address: From:

To:

Next prior address, if applicable:

Street Address Apt/Ste/Flr Unit# City State / Province / Region ZIP / Postal Code Country

Dates at this address: From:

To:

Your last address outside U.S. of more than one year (not necessarily within last the 5 years):

Street Address Apt/Ste/Flr Unit# City Province/Region Postal Code Country

Dates at this address: From:

To:

Any additional residences:

About Your Employment

If you consider yourself, or have considered yourself, “self employed”, either enter a location or put “various," where applicable.

Most recent employment:

Employer Name

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation (specify)

Dates at this job: From:

to:

Untitled

This is my current job.

Other employment(s) during last 5 years both inside or outside the U.S.:

Employer Name

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation (specify)

Dates at this job: From:

to:

Untitled

This is my current job.

Other employment(s) during last 5 years both inside or outside the U.S.:

Employer Name

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation (specify)

Dates at this job: From:

to:

Untitled

This is my current job.

Last occupation abroad (if not described already):

Employer Name

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation (specify)

Dates at this job: From:

to:

Untitled

This is my current job.

Enter any additional jobs here:

Are there any other special details we should know about the answers you've given?

(This is for our use only, to help you with your case.)

Main Questionnaire

About You (The Applicant)

About Your Parents

About Your Spouse(s)

About Your Children

About Where You've Lived

About Your Employment

Your Immigration Status

Your Memberships

Your Financial Overview

Income Assistance Details

Institutionialization History

Accommodations for Individuals With Disabilities/Impairments

Travel Information (For Travel Authorization)

Communicable diseases of public health significance