Permanent Residency Questionnaire Please complete this form. If you need more writing space, feel free to attach additional pages. Your name: First Middle Last Maiden Present Address: Number and Street City/Town State & Zip Code Country Your last address outside the United States: Number and Street City/Town Province Country Phone Number Date entered residence (Month/Year) Last date at residence (Month/Year) Contact Information: Home Work Cell Email Address City/Town of Birth Country of Birth Date of birth (Month/Day/Year) Country Passport Issued From: Passport number Issue date Expiration date Country(ies) of Citizenship U.S. Social Security Number I-94 Entry/Departure Record Admission Number Entry Valid Until (Date) Date of last entry into U.S. Place of last entry into U.S. What is your current status in U.S. U.S. Visa Issued: Where When Valid Until (date) Category (B, F, H, I, J, etc) At which U.S. embassy or consulate would you like to use to obtain a visa if not changing status in the U.S.? What was your first date of entry into the U.S. in your current status. Has an immigrant petition to afford you permanent resident status ever been filed on your behalf? If yes: Who filed (family member or employer) Where and when filed Status of application Have you ever applied to adjust your status to permanent resident based on a pending or approved immigrant petition? If yes: Where and when Status of application Has an application for labor certification ever been filed on your behalf? If yes: Where Status Have you ever been in the U.S. as a J-1 Exchange Visitor? If yes: When Are you subject to the 212(e) two-year home residency requirement? Have you ever been the subject of a deportation proceeding? If yes: When Where Outcome Have you ever made a fraudulent statement or misrepresented a fact to obtain or try to obtain any immigration benefit from the U.S.? If yes, please explain. Have you ever claimed to be a U.S. citizen either on an I-9 or any other federal document? If yes, please explain. If in the U.S., do you have plans to travel abroad? If yes, provide details of your travel plans. Do you belong to any organizations (including political, social, educational and professional groups) in the U.S. or anywhere in the world? If yes please list the name and address of organization and the dates of membership (month/year to month/year) Do you fear persecution if you are required to return to the country of your nationality or last residence? If yes, please explain. Personal Background (If answered Yes, please explain): Have you ever been: a. treated for mental disorder, retardation, drug addiction or alcoholism? b. arrested (even if not convicted) of any crime, detained, or confined in a prison? c. beneficiary of a pardon, amnesty, rehabilitation decree, or other act of clemency? d. convicted of any crime in the U.S. or anywhere in the world? (Including convictions that were expunged) (Excluding minor traffic offences)? e. involved with illegal use/trafficking of drugs, narcotics, marijuana in the U.S. or anywhere in the world? f. a member of any communist or totalitarian party? g. engaged in prostitution in the U.S. or anywhere in the world? h. given assistance to other aliens to come to the U.S. illegally? i. ever had TB or other contagious diseases? j. received public assistance in this country from any source? Marital status (Single, Married, Separated, Divorced, or Widowed) If previously married, provide the following for your former spouse(s): Name of former spouse(s) Date of Birth Date and Place of Marriage Date and Place of Divorce Date of Death (If Deceased) If you have children, provide for each child (if any are stepchildren or children by another spouse, indicate which and give details): Full Name Sex Marital Status Date of Birth City/Country of Birth Country(ies) of Citizenship U.S. Immigration Status Social Security Number (if any) Present Address Your Parents: Father - Family Name Given Name Date of Birth City/Country of Birth Citizen of which Country(ies) Now lives at (City/Country) Ever a U.S. Citizen If Deceased, Date Deceased Mother - Family Name Given Name Maiden Name Date of Birth City/Country of Birth Citizen of which Country(ies) Now lives at (City/Country) Ever a U.S. Citizen If Deceased, Date Deceased Do you have a grandparent that was ever a U.S. Citizen? Do you have any relative living in the U.S., or who once lived in the U.S., or are/were U.S. citizens? If yes list: Name Address Relationship Current/Former U.S. Immigration status Current profession List each employer for the past five years. (Attach Resume/C.V.) Please provide: Name of Employer Address Occupation/Title Start Date (Month/Year) Finish Date (Month/Year) List each residence lived at for last five years. Please provide: Home address City and Country Date entered residence (month/year) Last date at residence (month/year) Have you ever been in any military service? If yes, please provide: Branch Rank/Position Date of service Military Specialty/occupation Do you have a U.S. drivers license? If so: U.S. state in which drivers license was issued Date drivers license expires If this is an employment-based application process, are you responsible for payment of any portion of the cost of this application? If yes, please describe the costs you are responsible for paying. Did you ever have an employment authorization document (EAD) for optional practical training (OPT) in F-1 status as an international student? If so, did you have more than 60 days of unemployment during your approved period of OPT? If yes, please explain your periods of unemployment during OPT in detail. Physical location where you will be (or are) working based on the immigration approval you are seeking: Number and Street City/Town State & Zip Code CHECKLIST OF DOCUMENTATION WE WILL NEED Please provide us with copies of the following materials which apply to you: 1. Your passport pages: • picture/biographical identification pages • any pages with American Consulate issued visas • any pages with U.S. entry stamps 2. Most recent I-94 card, front and back 3. Resume/Curriculum vitae 4. Birth Certificate 5. Military record, if any 6. Proof of termination of any prior marriage (divorce decree or death certificate), if any 7. If ever convicted of a crime, provide certified copy of court and prison records Please note that if documents are not in English, we will need an exact English translation and translator’s affidavit. The translations may be made by any person who is capable of translating the documents. We can provide a form for the translator’s affidavit. We also can provide translation services in our office or through an outside agency.