IMMIGRATION BACKGROUND QUESTIONNAIRE
Please complete this questionnaire to the best of your ability and bring it to your consultation.
DATE:______
How did you hear about our firm? q Flyer posted at :______q Internet? q Magazine Ad?
q Facebook? q Referral from ______. q Other:______
(Name)
I. INFORMATION ABOUT YOU
Name:
(First), (Middle), (LAST)
Other names: Sex: q Male q Female
(Maiden, Religious, Professional, Aliases)
Date of birth: Place of birth:
(Mo/Day/Yr) (City), (State), (Country)
Citizenship: U.S. Social SecurityNo.
(Country)
Address: ______Apt. #___ City ______State:__ Zip _____
E-Mail: ______Telephone: ______Cell: ___
If in the U.S., complete the following:
Date of arrival: I-94No.:
(Mo/Day/Yr)
Current nonimmigrant status: Expires:
(Mo/Day/Yr)
Place where last entered U.S.: Means of travel into U.S.:
Did the Border Patrol, Customs, or Pre-Flight Inspector see you when you entered the USA?
PassportNo.: Date issued: Date expires:
(Mo/Day/Yr) (Mo/Day/Yr)
Do you have an “Alien Number” or “A Number”? A______- ______- ______
Are any of your family members U.S. citizens or have a greencard? qYes qNo
If “yes,” who? Mother __ Father __ Spouse __ Child __ Other ______
Has anyone in your home country ever hurt you before because of your race, religion, nationality, social group, or political opinion? qYes qNo
If you went back to your home country today, are you afraid that someone would hurt you because of your race, religion, nationality, social group, political opinion, or any other reason? qYes qNo
Since you came to the USA, have you been the victim of crime? Has anyone beaten you, stabbed you, shot you, or threatened your life? qYes qNo
II. MARITAL INFORMATION
Marital status: q Married q Widowed q Divorced qSeparated q Single
Is your spouse in the U.S.? qYes qNo If not, where is your spouse?______
Spouse’s Name:
(Last), (First), (Middle)
Other names: Sex: q Male qFemale
(Maiden, Religious, Professional, Aliases)
Date of birth: Place of birth:
(Mo/Day/Yr) (City), (State), (Country)
Citizenship: U.S. Social SecurityNo.
Date of marriage: Place of marriage:
Were you married previously? q Yes q No
III. LIST CHILDREN, INCLUDING STEPCHILDREN
Name(First, Last) / Relationship / DOB / City/State/
Country of Birth / Applying with you / Immig Status
1.
Address:
2.
Address:
3.
Address:
4.
Address:
IV. IMMIGRATION-RELATED QUESTIONS
Ever under immigration (deportation) proceedings, or ever get arrested by Immigration? qYes qNo
Where: When:
Ever applied for a U.S. nonimmigrant visa at the Embassy before? qYes qNo
If yes, Classification: ______Where: When:
Outcome? q Issued q Refused
V. GROUNDS OF EXCLUSION
1. Have you ever in or outside the United States:
a. Been arrested or put in handcuffs? qYes qNo
Put in jail for any reason? qYes qNo
Seen a judge? qYes qNo
2. Have you ever:
a. Within the past 10 years been a prostitute or procured anyone for prostitution? qYes q No
b. Done illegal gambling?
qYes q No
c. Smuggled immigrants into the U.S. illegally?
q Yes q No
d. Trafficked or sold illegal or prescription drugs? qYes qNo
3. Are you a terrorist or support terrorists? qYes qNo
4. Have you ever beaten or killed someone because of their race, religion, nationality, ethnic origin, or political opinion? q Yes q No
5. Were you ever turned back from the USA when you tried to enter, with or without a visa? q Yes q No
6. Have you ever lied or not told the truth to get an immigration benefit like a visa or a greencard? q Yes qNo
7. 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? qYes qNo
I, ______, certify that the information provided on this questionnaire is true and correct to the best of my knowledge.
Date:
Signature