I. PERSONAL INFORMATION

Name: (First, middle, last): ____________________________________________________

Sex ( male / Female): ______________

Maiden name (female): _______________________________________________________

Other names: _______________________________________________________________

Date of birth (mo/day/yr): _____________ City of birth:______________________________

Nationality: _____________________

Present address: _____________________________________________________________

Permanent address: _________________________________________

Phone _____________________________

II. MARITAL STATUS

Single______Married______Divorced______Widowed_______

Name of spouse ( first, middle, last ): _____________________________________________

Date of birth of spouse(mo/day/yr): ________________________

City and country of birth of spouse: ________________________

Date of present marriage(mo/day/yr): _________________

City and country of present marriage: _________________

Your spouse's Immigration status( permanent resident / citizen / other )___________________

Last adress at which you and your spouse resided together:_____________________________

Date since you and your spouse last resided at this address(mo/day/yr):____________________

Are you and your spouse residing together?( yes / no ) ______________

Former spouse(s)( yes / no):___________

Name of former spouse ( first, middle, last ): _______________________________

Date of Birth(mo/day/yr): __________________________________

Date(mo/day/yr) and place of marriage: _______________________

Date(mo/day/yr) and place of termination of marriage: ___________

Former Spouse(s) of Your Current Spouse ( yes / no):___________

Name of former spouse of your current spouse ( first, middle, last ): _________________

Date of Birth(mo/day/yr): __________________________________

Date(mo/day/yr) and place of marriage: _______________________

Date(mo/day/yr) and place of termination of marriage: ____________

III. FAMILY INFORMATION

Children

How many children do you have?: _____________________

Name (first, middle, last): _______________________________________________

Sex ( male / Female): _______________________________

Date of Birth (mo/day/yr): ___________________________

City, Country of Birth: _______________________________

City, Country of current residence: _____________________

Parents

Father's Name( first, middle, last ): ________________________________________

Date of Birth(mo/day/yr): _______________________

City and Country of Birth: _______________________

Current address : _______________________________________________________

Indicate if deceased ( yes / no): ______________

Mother's Name ( first, middle, last ): _________________________________________

Mother's Maiden Name ( first, middle, last ): ___________________________________

Date of Birth(mo/day/yr): ______________________

City and country of Birth: ______________________

Current address : ________________________________________________________

Indicate if deceased ( yes / no): _______________

Have you relatives residing in the USA ( yes / no): ________

Name ( first, middle, last ): _________________________________________________

Sex ( male / Female): ______________________

Date of Birth(mo/day/yr): ______________________

Type of relationship ______________________

Date of entry to US ______________________

Current address : _________________________________________________________

IV. ADDRESSES

Last two addresses:

Street Address ____________________________________________________________

City State/Province Country: _________________________________________________

From (mo/yr) _______________ To (mo/yr) _________________

Street Address ____________________________________________________________

City State/Province Country: _________________________________________________

From (mo/yr) _______________ To (mo/yr) _________________

V. VISA INFORMATION

Date of entry into the U.S. (mo/day/yr): ________________________

Port of entry into the U.S.: ______________________________________________

Name of vessel or other means of travel: ________________________________

Was your permanent residence ever revoked for being outside the U.S. for more than one year? ( yes / no): ___________

If yes, give the Date of revocation: _______________________

Passport No.: ________________________________________

Where issued: _______________________________________

Type of visa: ________________________________________

Place where visa issued: _______________________________

I-94 card no. (Arrival/Departure Card): ___________________

VI. EMPLOYMENT HISTORY

For the last five years ( list most recent first):

Employer's Name:___________________________________________________________________

Employer'sAddress: __________________________________________________________________

Job Title: __________________________________________________________________________

Salary: _____________________

Hours perWeek: ______________

Dates of employment.

From: (mo/yr) ________________ To: (mo/yr) _________________

VII. EDUCATIONAL INFORMATION

Please list trade schools, colleges and/or universities attended (most recent first)

From (mo/yr) _______________ To (mo/yr) ______________

Name City & Country _____________________________________________________________

Field of Study _______________________________________________________________________