I

I. PERSONAL INFORMATION

1. Name (Family Name, First Name, Middle Name)

____________________________________________________________________________

2. Sex (Male or Female) ____________

3. Date of Birth (Month, Day, Year)

4. Place of Birth (City or Town, Province or State, & Country)

____________________________________________________________________________

5. Country where your passport was issued

6. Address in Home Country (No. & Street, Apt. No., City or Town, Province, Country)

____________________________________________________________________________

7. Current Address

____________________________________________________________________________

8. Telephone Number ( ) _________-_____________________

Work or Alternate Telephone Number ( ) _________-_________________

9. Fax Number ( ) _________-______________________

10. E-mail address ________________________

11. Social Security Number (If None, Write "None") ________________________________

12. Occupation or Profession ____________________________________________________

13. Have you ever been arrested? (If yes, please attach an explanation)

No_________ YES__________

II. MARITAL STATUS

(PLEASE CIRCLE ONE)

IF MARRIED

1. Name of Spouse (Family Name, First Name, Maiden Name) ____________________________________________________________________________

2. Date of Birth (Spouse) (Month, Day, Year) _____________________________________

3. Place of Birth (Spouse) (City or Town, State or Country) ____________________________________________________________________________

4. Spouse's Passport Number _____________________________

Expiration Date ______________________________________

Country of Issue _____________________________________

5. Is your Spouse a Permanent Resident? (Yes or No) _________

If YES: Give Date (Month, Day, Year) and Place of Permanent Residence (City, State or Country) ____________________________________________________________________________ ____________________________________________________________________________ What is your SPOUSE'S Alien Registration No.___________________________________

6. Is your SPOUSE a U.S. Citizen? (Yes or No) ____________

If YES, By Birth or By Naturalization ________________________

On (Date) ____________ At (Place) __________________________

III. FAMILY INFORMATION

1. Number of Children _______

FOR ALL YOUR CHILDREN:

NAME, SEX, PLACE OF BIRTH, DATE OF BIRTH, NOW LIVING AT

____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

MEMBERS OF YOUR FAMILY WHO WANT TO ENTER THE USA WITH YOU:

NAME, RELATIONSHIP

IV. ADDRESSES

1. RESIDENCES LAST FIVE YEARS (LIST PRESENT ADDRESS FIRST)

(STREET & NO., APT.#, CITY, STATE, COUNTRY, FROM (MONTH/YEAR), TO (MONTH/YEAR) ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

V. VISA INFORMATION

1. Have you ever applied for an Immigrant or Nonimmigrant U.S. Visa before? No_________ YES__________

WHERE?_____________________________WHEN?______________________________ ___________VISA WAS ISSUED

___________VISA WAS REFUSED

TYPE OF VISA?_________________________

2. Has your U.S. Visa ever been canceled?

No_________ YES__________

3. (a) Has anyone ever filed an Immigrant Visa petition on your behalf? (b) Has Labor Certification for Employment in the U.S. ever been requested by you or on your behalf? (c) Have you or anyone acting for you ever indicated to a U.S. Consular or Immigration Employee a desire to immigrate to the U.S.?

(a) NO ________ YES ________

(b) NO ________ YES ________

4. Are any of the following in the U.S.? (If YES, Circle Appropriate Relationship and indicate what that person is doing in the U.S., I.E., STUDYING, WORKING, ETC.)

HUSBAND/WIFE___________________

FIANCE/FIANCEE__________________

FATHER/MOTHER__________________

SON/DAUGHTER___________________

BROTHER/SISTER__________________

IF YOU ARE PRESENTLY IN THE U.S., PLEASE ANSWER THE FOLLOWING:

5. Date you last entered the U.S. (Month, Day, Year)_______________________________

6. Type of Visa with which you entered: (Circle One)

B-1 | B-2 | C-1 | D-1 | E-1 | E-2 | F-1/F-2 | H-1 | H-2 | J-1/J-2 | K-1 | Other

7. Date and City where your visa was issued (Date and US Embassy/Consulate) ____________________________________________________________________________

VISA#_____________________________

I-94#______________________________

8. Expiration Date of Visa _______________

9. Expiration Date of Authorized Stay (I-94)__________

10. Passport Number_____________________________

Date your Passport was issued____________ Date your Passport expires_____________

11. Are you or have you ever been lawfully admitted to the U.S. as a Permanent Resident? YES_________ NO__________

IF YES: What is your Alien Registration Number?________________________________

Name as it appears on your Alien Registration Card_______________________________ Date (Month, Day, Year) and Place (City, State) where your Alien Registration Card was issued____________________________________________________________________

12. Did you Voluntarily give up your Permanent Residence in the U.S.?

YES_________ NO__________

13. Was your Permanent Residence ever revoked for being outside the U.S. for more than one year?

YES_________ NO__________

If YES, Give approximate date___________________________________

14. Have you ever been refused admission to the U.S.?

YES_________ NO___________

If YES, Please explain_______________________________________________________

15. State the dates of previous Residence or Visits to the U.S. (DATE OF ENTRY, TYPE OF VISA, DATE OF DEPARTURE) ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

VI. EDUCATIONAL BACKGROUND

Education in the U.S. If your degree was obtained in the U.S., attach a copy of each degree you have (i.e., if you have a Ph.D., also attach a copy of your Masters and Bachelor's)

Education Abroad. If your degree was obtained outside the U.S., attach a copy of the degree and certified translation. Also indicate the following:

Dates of Attendance Degree Earned

Name of School From (month & year): To: (Equiv. to U.S. degree)

______________________ _______ _______ Bachelor

______________________ _______ _______ Masters

______________________ _______ _______ Doctorate

VII. EMPLOYMENT INFORMATION

1. Number of years work experience_______

(List Previous Employment, Most Recent First--Give at least 5 year history, If Applicable)

2. Job Title ____________________________________________________

Salary ____________ Hours Per Week ______

Name of Employer___________________________________________________________

Type of Business_____________________________________________________________

Address of Employer_________________________________________________________ From_________ 19__________ to ___________ 19 ____________

Equipment, Tools, Hardware, Software, Etc. Used on Job__________________________ _____________________________________________________________________________

Job Duties _________________________________________________________________ _____________________________________________________________________________

3. Job Title ____________________________________________________

Salary ____________ Hours Per Week ______

Name of Employer___________________________________________________________

Type of Business_____________________________________________________________

Address of Employer_________________________________________________________ From_________ 19__________ to ___________ 19 ____________

Equipment, Tools, Hardware, Software, Etc. Used on Job__________________________ _____________________________________________________________________________

Job Duties _________________________________________________________________ _____________________________________________________________________________

4. Job Title ____________________________________________________

Salary ____________ Hours Per Week ______

Name of Employer___________________________________________________________

Type of Business_____________________________________________________________

Address of Employer_________________________________________________________ From_________ 19__________ to ___________ 19 ____________

Equipment, Tools, Hardware, Software, Etc. Used on Job__________________________ _____________________________________________________________________________

Job Duties _________________________________________________________________ _____________________________________________________________________________

IF YOU HAVE HELD MORE THAN THREE JOBS, PLEASE PROVIDE THE REQUESTED INFORMATION ABOUT THESE JOBS ON A SEPARATE PIECE OF PAPER.

IF YOU INTEND TO APPLY FOR A EMPLOYMENT BASED VISA, PLEASE FILL OUT THE FOLLOWING (If you plan on obtaining a visa by different means, disregard this section)

INFORMATION ABOUT THE JOB AND EMPLOYER

Please answer as fully and accurately as possible. If pertinent material (e.g., company brochure, job description, marketing brochure) is available, please attach a copy.

1. Name (name of organization or individual)___________________________________________

2. Address (number & street, city, county, state, zip code)

____________________________________________________________________________________

3. Telephone number (____)_____-__________ Fax # (____)_____-__________

IRS Employer I.D. Number______________________

4. Person who will sign the job offer

______________________________________ ______________________________

Name (first & last) Title

5. General information about the employer

Date business established____________ Number of employees:__________

Annual Gross $____________________ Annual Net $__________________

A brief, nontechnical description of the nature of the business activity__________________

____________________________________________________________________________________________________________________________________________________________

6. Job title_____________________________________________________________________

7. Job duties (describe in detail)___________________________________________________

Qualifications needed to perform the job duties_____________________________________

____________________________________________________________________________________________________________________________________________________________

Reasons why the individual was chosen over other candidates for the position (i.e., special skills, education, knowledge about particular aspect of the work)___________________________

______________________________________________________________________________

Number of employees supervised:_________

8. Hours worked per week:_________________ From ______ a.m. to _______ p.m.

Pay rate (specify per hour, week, month, or year):__________________

Anticipated overtime hours per week:_________ Overtime rate:__________________

If you receive additional benefits such as commissions or room & board, please describe:____________________________________________________________________

9. Other information about the job

Number of employees who perform the same work_________

If this is a newly created position or, how long has it existed__________________________

Title of your anticipated immediate supervisor_____________________________________

Address where you will work IF different than that listed above_______________________

______________________________________________________________________________

III. MISCELLANEOUS INFORMATION

A VISA MAY NOT BE ISSUED TO PERSONS WHO ARE WITHIN SPECIFIC CATEGORIES DEFINED BY LAW AS INADMISSIBLE TO THE UNITED STATES (EXCEPT WHEN A WAIVER IS OBTAINED IN ADVANCE). COMPLETE INFORMATION REGARDING THESE CATEGORIES AND WHETHER ANY MAY BE APPLICABLE TO YOU CAN BE OBTAINED FROM THIS OFFICE. GENERALLY, THEY INCLUDE PERSONS:

--Afflicted with Contagious Diseases (I.E., Tuberculosis) or who have suffered serious Mental Illness:

--Arrested, Convicted for any offense or crime even though subject of a Pardon, Amnesty, or other such legal action;

--Believed to be Narcotic Addicts or Traffickers;

--Removed, Excluded or Deported from the U.S.A. at any time;

--Who have sought to obtain a Visa by Misrepresentation or Fraud;

--Who are or have been members of certain organizations including Communist Organizations and those Affiliated therewith;

--Who Ordered, Incited, Assisted, or Otherwise participated in the Persecution of any person because of Race, Religion, National Origin, or Political Opinion under the control, Direct or Indirect, of the Nazi Government of Germany, or of the Government of any area occupied by, or Allied with, the Nazi Government of Germany.

Do any of these appear to apply to you? __________ No __________ YES

If YES, Please attach an explanation.

PLEASE ATTACH ANY ADDITIONAL INFORMATION OR IMMIGRATION CONCERNS THAT YOU MAY WISH TO ADD TO THIS QUESTIONNAIRE ON A SEPARATE PIECE(S) OF PAPER