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.