Visa, been refused admission to the United States, or withdrawn your application for admission at the port of entry? 4ĥ Work / Education / Training Information WORK Primary Occupation: Present Employer or School Name: Address: Does this job require at least 2 years of training or experience? Job Title: Duties: Employment Date From: Do you have other occupations? In which occupation do you intend to work in the U.S.? Were you previously employed? Employer Name (1): Employer Address: Telephone Number: Job Title: Supervisor's Surnames: Supervisor's Given Names: Employment Date From: 5Ħ Employment Date To: Does this job require at least 2 years of training or experience? Duties: EDUCATION Have you attended any educational institutions at a secondary level or above? Highest Level of Education Completed: Number of Educational Institutions Attended: Name of Institution (1): Address of Institution: Course of Study: Degree or Diploma: Date of Attendance From: Date of Attendance To: Name of Institution (2): Address of Institution: Course of Study: Degree or Diploma: Date of Attendance From: Date of Attendance To: Name of Institution (3): 6ħ Address of Institution: Course of Study: Degree or Diploma: Date of Attendance From: Date of Attendance To: TRAINING Have you ever served in the military? Have you belonged to, contributed to, or worked for any professional, social, or charitable organization? Do you have any specialized skills or training, including firearms, explosives, nuclear, biological, or chemical experience? Have you ever served in, been a member of, or been involved with a paramilitary unit, vigilante unit, rebel group, guerrilla group, or insurgent organization? Can you speak and/or read languages other than your native language? 7Ĩ Security and Background Information Do you have a communicable disease of public health significance such as tuberculosis (TB)? Do you have documentation to establish that you have received vaccinations in accordance with U.S. Date Arrived: (1): Length of Stay: Date Arrived: (2): Length of Stay: Date Arrived: (3): Length of Stay: Date Arrived: (4): Length of Stay: Date Arrived: (5): Length of Stay: Have you ever been issued a U.S.
Travel Information Have you ever been in the U.S.? Were you issued an Alien Registration Number by the Department of Homeland Security? Provide information on your last five U.S. Phone Number: Is this address where you want your Permanent Residence Card (Green Card) mailed? 2ģ Family Information Name Provided: Father's Surnames: Father's Given Names: Date of Birth: City of Birth: State/Province of Birth: Country/Region of Birth: Is your father still living? Current Address: Surnames at Birth: Mother's Given Names: Date of Birth: City of Birth: State/Province of Birth: Country/Region of Birth: Is your mother still living? Is your mother's address the same as your father's? Do you have any Previous Spouses? Do you have any children? 3Ĥ Previous U.S.
1 Personal, Address, and Phone Information Name Provided: Full Name in Native Language: Other Names Used: Sex: Current Marital Status: Date of Birth: City of Birth: State/Province of Birth: Country/Region of Birth: Country/Region of Origin (Nationality): Document Type: Document ID: Country/Authority that Issued Document: Issuance Date: Expiration Date: Do you hold or have you held any nationality other than the one you have indicated above? Present Address: From Date: Have you lived anywhere other than this address since the age of sixteen? Previous Address (1): 1Ģ From: To: Previous Address (2): From: To: Primary Phone Number: Secondary Phone Number: Work Phone Number: Address: Is your Mailing Address the same as your Present Address? Name of person currently living at address: U.S.