GENERAL IMMIGRATION CASE INTAKE FORM




Required fields are marked with *.

I. INFORMATION ABOUT THE APPLICANT


Name*:

Other names:

Sex*: MaleFemale

Birth Date*:

Place of Birth*:

Country(ies) of Citizenship*:

US Social Security Number (SSN):

Permanent address abroad*:

Email*:

Phone*:

Phone #2:

Fax:

Address in the USA:

If you are in the United States, answer the following questions:

Date of arrival in the USA:

I-94 number:

Current Immigration Status:

Expiration Date of Current Visa:

Place you last entered the USA:

Manner of entry to the USA:

Non-immigrant status:

Did you speak with a US customs official in the course of your last entry to the United States?

Passport Number:

Passport issued date:

Passport expiration date:

Hair color*:

Eye color*:

Height (feet and inches, please)*:

Identifying marks (scars, tattoos, etc.):

Skin complexion*:

Parental Information

Father's name*:

Father's birth date*:

Father's place of birth*:

Father's current residence*:

Mother's name*:

Mother's birth date*:

Mother's place of birth*:

Mother's current residence*:

Were any of your grandparents or spouse's grandparents born in the USA? YesNo

If yes, when?

Were you or your spouse born in Canada with at least 50% Native ancestry? YesNo

Are you or your spouse eligible for Native American tribal membership? YesNo

II. MARITAL INFORMATION

Marital Status*: MarriedWidowedDivorcedSeparatedSingle

Will your spouse accompany you to the USA? YesNo

Name of spouse:

Other names of spouse:

Sex of spouse: MaleFemale

Spouse's birth date:

Spouse's birth place:

Spouse's country(ies) of citizenship:

Spouse's US Social Security Number:

Date of marriage:

Place of marriage:

Name of any ex-spouse(s) of your spouse, their respective countries of citizenship, and dates of divorce or death:

Does your spouse currently work in the USA? YesNo


If yes, does he or she have authorization to work full-time in the USA? YesNo


If no, does he or she wish to work in the USA? YesNo

Have you ever been married before? YesNo

Name of your first former spouse:

Birth date of your first former spouse:

Place of birth of your first former spouse:

Country(ies) of citizenship of your first former spouse:

Date that your marriage to first former spouse ended (by divorce or death):

Place of divorce with first former spouse:

Name of your second former spouse:

Birth date of your second former spouse:

Place of birth of your second former spouse:

Country(ies) of citizenship of your second former spouse:

Date that your marriage to second former spouse ended (by divorce or death):

Place of divorce with second former spouse:

III. LIST ALL BROTHERS, SISTERS, CHILDREN, AND STEPCHILDREN

Please include the first name, last name, relationship, date of birth, city/state/country of birth, and US immigration status of every brother, sister, child, and stepchild you have:


(Each person on a separate line. If none, write "none.")

Do you have children under the age of 4 years old who may eventually want to live permanently in the USA?
YesNo

IV. RESIDENCES FOR THE LAST FIVE YEARS (last address first)

Current address*:

When did you begin residing at this address?*

Previous address (1):

When did you begin residing at this address?

Previous address (2):

When did you begin residing at this address?

Previous address (3):

When did you begin residing at this address?

Previous address (4):

When did you begin residing at this address?

Previous address (5):

When did you begin residing at this address?

Your last residential address outside the United States where you lived for at least one year*:

When did you begin residing at this address?*

When did you stop residing at this address?*

V. CURRENT AND PAST ASSOCIATION IN GROUPS OF ANY KIND, INCLUDING MILITARY, SINCE YOUR 16TH BIRTHDAY

For each group or association in which you have ever been a member, please indicate (1) the name of the group, (2) city/state/country, and (3) the dates of your participation:

(If none, please write "none.")*

VI. APPLICANT'S EDUCATION

For each school, college or university in which you have ever studied, please write (1) the name of the school, (2) address of the school, (3) area of study, (4) the dates you studied there, (5) any diploma, degree or certificate that you received.

One school per line:*

Professional license(s):

How are your English language skills? Did you ever take any courses or studies in English? What other language(s) do you speak?*

VI. APPLICANT'S PREVIOUS WORK EXPERIENCE

Please write a list of every employer where you have worked for the past five years (whether in the United States or abroad) beginning with your current employer, if any. Also include your position for every job, the address of every employer, the dates you began and ended your job at each employer, and your job duties at each employer.


Current employer (if none, write "none"):*





Prior employer (1):





Prior employer (2):





Prior employer (3):





Prior employer (4):





What was your last occupation abroad?




VII. IMMIGRATION-RELATED QUESTIONS

Have you ever been placed in removal proceedings?* YesNo
ExclusionDeportationRecissionImmigration Court

Where:

When:

Have you ever requested a non-immigrant visa to the United States before?* YesNo

If yes, what classification:



Where:



When:



What was the result?

GrantedDenied

Visa number:



Have you ever had a US visa cancelled?

YesNo

Do you intend on applying for an immigrant visa abroad?

YesNo

If yes, where:



Do you plan to adjust status in the United States?

YesNo

If yes, where:



VIII. GROUNDS OF INADMISSIBILITY*

Have you ever (in the United States or abroad):*

Knowingly committed any crime of moral turpitude or a drug-related offense for which you have not been arrested?
YesNo

Been arrested, cited, charged, indicted, fined or imprisoned for breaking or violating any law or ordinance, excluding traffic violations?

YesNo

Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency or similar action?

YesNo

Exercised diplomatic immunity to avoid prosecution for a criminal offense?

YesNo



If you answered YES to any of the above, provide the following information:

(1) Date , (2) place (city, state, country), (3) nature of offense, and (4) the outcome.

If NO to all answers, write "none."*



Have you ever 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?*

YesNo

If yes, please explain:

Do you have any serious medical condition(s) that require ongoing medical treatment?* YesNo

If you answered "Yes" please explain the condition(s) and how you intend on receiving treatment in the USA:

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? YesNo

b. Engaged in any unlawful commercialized vice, including but not limited to illegal gambling? YesNo

c. Knowingly encouraged, induced, assisted, abetted or aided any alien to try to enter the U.S. illegally? YesNo

d. Illicitly trafficked in any controlled substance or knowingly assisted, abetted or colluded in the illicit trafficking of any controlled substance? YesNo

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? YesNo

Do you intend to engage in the U.S. in: *

a. Espionage?
YesNo

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?
YesNo

c. Any activity to violate or evade any law prohibiting the export from the United States of goods, technology or sensitive information?
YesNo

Have you ever been a member of, or in any way affiliated with, the Communist Party or any other totalitarian party?
YesNo

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?

YesNo

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?

YesNo

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?

YesNo

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?

YesNo

Have you ever left the U.S. to avoid being drafted into the U.S. Armed Forces?

YesNo

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?

YesNo

Are you now withholding custody of a U.S. citizen child outside the U.S. from a person granted custody of the child?

YesNo

Do you plan to practice polygamy in the U.S.?

YesNo

If you answered YES to any of the above, explain fully:






I*, , certify that the information provided on this questionnaire is true and correct to the best of my knowledge.