Questionnaire for applicant

Step 1 of 10

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 and country of birth

5. Father is deceased:

Yes

6. Father’s city and country of residence

Father's Country of Residence

7. Mother’s current name

First Middle Last

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

First Middle Last

9. Mother’s date of birth

10. Mother’s city and country of birth

Mother's country of birth

11. Mother is deceased:

Yes

12. Mother’s current city and country of residence

Mother's 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:

Your Immigration Status

Date of last entry into the US:

Place of last entry into the US:

City State / Province / Region

Passport number used at last arrival:

When I last arrived in the United States, I:

Was inspected at a port of entry and admitted

Was inspected at a port of entry and paroled

Came into the United States without admission or parole

Other

I was admitted as:

I was paroled as:

Explain:

Have you ever applied for Permanent Resident status in the US?

Yes

If so, please provide:

1. Location of U.S. Embassy or Consulate:

2. Decision:

3. Date of decision:

Your Memberships

List all present and past membership in or affiliation with every organization, association, fund, foundation, party, club, society, or similar group in the US or in other places since your 16th birthday, including military service.

Organization 1:

Name of organization

Address

City State / Province / Region Country

Nature of organization:

Dates of membership: From:

to:

I am still a member:

Yes

Organization 2:

Name of organization

Location of organization:

City State / Province / Region Country

Nature of organization:

Dates of membership: From:

to:

I am still a member:

Yes

Organization 3:

Name of organization

Address

City State / Province / Region Country

Nature of organization:

Dates of membership: From:

to:

I am still a member:

Yes

List any additional memberships here:

CoveyLaw

Questionnaire for applicant

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