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Home
About Us
Immigration Services
USCIS Processing Times
Visa Bulletin
Immigration Approvals
Immigration News
Blog
中文
Contact Us
info@messersmithlaw.com
+1 305-515-0613
390 N Orange Ave, Suite 2300, Orlando, FL 32801
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Adjustment of Status Questionnaire
Questionnaires – Main Page
Adjustment of Status Questionnaire
Adjustment of Status Questionnaire
For Applying For Permanent Residency
The Messersmith Law Firm Immigration Lawyer Services
We make immigration possible
INFORMATION ABOUT YOU
Name
First
Middle
Last
Other Names Used 1
First
Middle
Last
Other Names Used 2
First
Last
Date of Birth
Email
Phone
Sex
Male
Female
Place of Birth (City / State / Country)
Country of Citizenship or Nationality
Alien Number (USCIS Number or A#)
Social Security Number (SSN)
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Race (Select All That Apply)
White
Asian
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Height (Feet - Inches)
Weight in Pounds
Eye Color
Black
Blue
Brown
Gray
Green
Hazel
Maroon
Pink
Unknown/Other
Hair Color
Bald (No hair)
Black
Blond
Brown
Gray
Red
Sandy
White
Unknown/Other
YOUR FINANCIAL INFORMATION
What is the size of your household?
Indicate your annual household income.
$0 - 27,000
$27,001 - 52,000
$52,001 - 85,000
$85,001 - 141,000
Over $141,000
Identify the total value of your household assets
$0 - 18,400
$18,401 - 136,000
$136,001 - 321,400
$321,401 - 707,100
Over $707,100
Identify the total value of your household liabilities (including both secured and unsecured liabilities)
$0
$1- 10,100
$10,101 - 57,700
$57,701 - 186,800
Over $186,800
What is the highest degree or level of school you have completed?
Grades 1 through 11
12th grade - no diploma
High school diploma, GED, or alternative credential
1 or more years of college credit, no degree
Associate's degree
Bachelor's degree
Master's degree
Professional degree (JD, MD, DMD, etc)
Doctorate degree
List your certifications, licenses, skills obtained through work experience, and educational certificates.
Have you ever received Supplemental Security Income (SSI), Temporary Assistance for Needy Families (TANF), or State, Tribal, territorial, or local, cash benefit programs for income maintenance (often called "General Assistance" in the State context, but which also exist under other names?
No
Yes
Have you ever received long-term institutionalization government expense?
No
Yes
ADDRESS HISTORY FOR THE PAST 5 YEARS
Current Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date From
Date To
Prior Address 1
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia (Republic of)
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States of America
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Date From
Date To
Prior Address 2
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia (Republic of)
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States of America
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Date From
Date To
Prior Address 3
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia (Republic of)
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States of America
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Date From
Date To
IMMIGRATION HISTORY
Passport Number Used At Most Recent Entery
Name of Country that Issued Your Passport
Date Passport Was Issued
Date Passport Expires
Location of US Embassy (City and Country) That Issued Your Visa Used to Enter the US
Nonimmigrant Visa Number
Place of Last Arrival to US (City, State)
Date of Last Arrival
I94 Number
I94 Expiration Date
Visa Status on I94
Current Visa Status
Date Current Visa Status Expires
Have You Ever Applied for an Immigrant Visa?
Yes
No
List Location of Embassy (City, Country)
Decision
Approved
Refused
Denied
Withdrawn
Date of Decision
EMPLOYMENT HISTORY FOR THE PAST 5 YEARS
Employer 1 (Current or Most Recent)
Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia (Republic of)
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States of America
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Job Title
Employment Start Date
Employment End Date
Employer 2
Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia (Republic of)
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States of America
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Job Title
Employment Start Date
Employment End Date
Employer 3
Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia (Republic of)
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States of America
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Job Title
Employment Start Date
Employment End Date
Most Recent Employer Outside of The US If Not Listed Above
Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia (Republic of)
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States of America
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Job Title
Employment Start Date
Employment End Date
INFORMATION ABOUT YOUR PARENTS
Father's Name
First
Middle
Last
Father's Name At Birth, If Different
First
Middle
Last
Date of Birth
Place of Birth (City & Country)
Place of Current Residence (City & Country)
Mother's Name
First
Middle
Last
Mother's Name At Birth, If Different
First
Middle
Last
Date of Birth
Place of Birth (City & Country)
Place of Current Residence (City & Country)
MARITAL HISTORY
What is Your Current Marital Status?
Single
Married
Divorced
Widowed
Marriage Annulled
Legally Separated
Current Spouse's Name
First
Middle
Last
Alien Number (USCIS Number or A#)
Date of Birth
Place of Birth (City / State / Country)
Date of Marriage
Place of Marriage (City / State / Country)
Prior Spouse's Name 1
First
Middle
Last
Date of Birth
Date of Marriage
Place of Marriage (City / State / Country)
Date Marriage Ended
Prior Spouse's Name 2
First
Middle
Last
Date of Birth
Date of Marriage
Place of Marriage (City / State / Country)
Date Marriage Ended
INFORMATION ABOUT YOUR CHILDREN
Child 1 Name
First
Middle
Last
Alien Number (USCIS Number or A#)
Date of Birth
Country of Birth
Child 2 Name
First
Middle
Last
Alien Number (USCIS Number or A#)
Date of Birth
Country of Birth
Child 3 Name
First
Middle
Last
Alien Number (USCIS Number or A#)
Date of Birth
Country of Birth
Child 4 Name
First
Middle
Last
Alien Number (USCIS Number or A#)
Date of Birth
Country of Birth
INADMISSIBILITY QUESTIONS
Have you ever been a member of, involved in, or in any way associated with any organiation, association, fund, foundation, party, club, society, or similar group in the US or in any other location in the world including any military service?
No
Yes
List the name(s) of organization(s), location(s), dates of membership, from and to, and the nature of the organization(s).
Have you ever been denied admission to the US?
No
Yes
Have you ever been denied a visa to the US?
No
Yes
Have you ever worked in the US without authorization?
No
Yes
Have you ever violated the terms or conditions of your nonimmigrant status?
No
Yes
Are you presently or have you ever been in removal, exclusion, rescission, or deportation proceedings?
No
Yes
Have you ever been issued a final order of exclusion, deportation, or removal?
No
Yes
Have you ever had a prior final order of exclusion, deportation, or removal reinstated?
No
Yes
Have you ever held lawful permanent resident status which was later rescinded?
No
Yes
Have you ever been granted voluntary departure by an immigration officer or an immigration judge but failed to depart within the allotted time?
No
Yes
Have you ever applied for any kind of relief or protection from removal, exclusion, or deportation?
No
Yes
Have you ever been a J nonimmigrant exchange visitor who was subject to the two-year foreign residence requirement?
No
Yes
Have you complied with the foreign residence requirement?
No
Yes
Have you been granted a waiver or has the Department of State issued a favorable waiver recommendation letter for you?
No
Yes
Have you ever been arrested, cited, charged, or detained for any reason by any law enforcement official?
No
Yes
Have you ever committed a crime of any kind even if you were not arrested, cited, charged with, or tried for that crime?
No
Yes
Have you ever pled guilty to or been convicted of a crime or offense even if the violation was subsequently expunged or sealed by a court, or if you were granted a pardon, amnesty, a rehabilitation decree, or other act of clemency?
No
Yes
Have you ever been ordered punished by a judge or had conditions imposed on you that restrained your liberty such as a prison sentence, suspended sentence, house arrest, parole, alternative sentencing, drug or alcohol treatment, rehabilitative programs or classes, probation, or community service?
No
Yes
Have you ever been a defendant or the accused in a criminal proceeding including pre-trial diversion, deferred prosecution, deferred adjudication, or any withheld adjudication?
No
Yes
Have you ever violated, or aatempted or conspired to violate, any controlled substance law or regulation of a state, the US, or a foreign country?
No
Yes
Have you ever been convicted of two or more offenses, other than purely political offenses, for which the combined sentences to confinement were five years or more?
No
Yes
Have you ever illegally trafficked or benefited from the trafficking of any controlled substances, such as chemicals, illegal drugs, or narcotics?
No
Yes
Have you ever knowingly aided, abetted, assisted, conspired, or colluded in the illicit trafficking of any illegal narcotic or other controlled substances?
No
Yes
Are you the spouse, son, or daughter of a foreign national who illicitly trafficked or aided, or otherwise abetted, assisted, conspired, or colluded, in the illicit trafficking of a controlled substance, such as chemicals, illegal drugs, or narcotics and you obtained, within the last five years, any financial or other benefit from the illegal activity of your spouse, parent, although you knew or reasonably should have known that the financial or other benefit resulted from the illicit activity of your spouse or parent?
No
Yes
Have you ever engaged in prostitution or are you coming to the US to engage in prostitution?
No
Yes
Have you ever directly or indirectly procured, or attempted to procure, or imported prostitutes or persons for the purpose of prostitution?
No
Yes
Have you ever received any proceeds or money from prostitution?
No
Yes
Do you intend to engage in illegal gambling or any other form of commercialized vice, such as prostitution, bootlegging, or the sale of child pornography, while in the US?
No
Yes
Have you ever exercised immunity, diplomatic or otherwise, to avoid being prosecuted for a criminal offense in the US?
No
Yes
Have you ever, while serving as a foreign government official, been responsible for or directly carried out violations of religious freedoms?
No
Yes
Have you ever induced by force, fraud, or coercion, or otherwise been involved in, the trafficking of persons for commercial sex acts?
No
Yes
Have you ever trafficked a person into involuntary servitude, peonage, debt bondage, or slavery? Trafficking includes recruiting, harboring, transporting, providing, or obtaining a person for labor or services through the use of force, fraud, or coercion.
No
Yes
Have you ever knowingly aided, abetted, assisted, conspired, or colluded with others in trafficking persons for commercial sex acts or involuntary servitude, peonage, debt bondage, or slavery?
No
Yes
Are you the spouse, son, or daughter of a foreign national who engaged in the trafficking of persons and have received or obtained, within the last five years, any financial or other benefit from the illegal activity of your spouse, parent, although you knew or reasonably should have known that the financial or other benefit resulted from the illicit activity of your spouse or parent?
No
Yes
Have you ever engaged in money laundering or have you ever knowingly aided, assisted, conspired, or colluded with others in money laundering or do you seek to enter the US to engage in such activity?
No
Yes
Do you intend to engage in any activity that violates or evades any law relating to espionage, including spying, or sabotage in the US?
No
Yes
Do you intend to engage in any activity in the US that violates or evades any law prohibiting the export from the US of goods, technology, or sensitive information?
No
Yes
Do you intend to engage whose purpose includes opposing, controlling, or overthrowing the US government by force, violence, or other unlawful means while in the US?
No
Yes
Do you intend to engage in any activity that could endanger the welfare, safety, or security of the US?
No
Yes
Do you intend to engage in any other unlawful activity?
No
Yes
Are you engaged in or, upon your entry into the US, do you intend to engage in any activity that could have potentially serious adverse foreign policy consequences for the US?
No
Yes
Have you ever committed, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property?
No
Yes
Have you ever participated in, or been a member of, a group or organization committed, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property?
No
Yes
Have you ever recruited members or asked for money or things of value for a group or organization that committed, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property?
No
Yes
Have you ever provided money, a thing of value, services or labor, or any other assistance or support for hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property?
No
Yes
Have you ever received any type of military, paramilitary, or weapons training?
No
Yes
Do you intend to engage in hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property?
No
Yes
Are you the spouse or child of an individual who ever committed, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property?
No
Yes
Are you the spouse or child of an individual who ever participated in, or been a member of, a group or organization committed, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property?
No
Yes
Are you the spouse or child of an individual who ever recruited members or asked for money or things of value for a group or organization that committed, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property?
No
Yes
Are you the spouse or child of an individual who ever provided money, a thing of value, services or labor, or any other assistance or support for hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property?
No
Yes
Are you the spouse or child of an individual who ever provided money, a thing of value, services or labor, or any other assistance or support for hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property?
No
Yes
Are you the spouse or child of an individual who ever received any type of military, paramilitary, or weapons training from a group or organization that committed, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property??
No
Yes
Have you ever assisted or participated in selling, providing, or transporting weapons to any person who, to your knowledge, used them against another person?
No
Yes
Have you ever worked, volunteered, or otherwise served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons?
No
Yes
Have you ever been a member of, assisted, or participated in any group, unit, or organization of any kind in which you or other persons used any type f weapon against any person or threatened to do so?
No
Yes
Have you ever served in, been a member of, assisted, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerilla group, militia, insurgent organization, or any other armed group?
No
Yes
Have you ever been a member of, or in any way affiliated with, the Communist Party or any other totalitarian party in the US or abroad?
No
Yes
During the period from March 23, 1933 to May 8, 1945, did you ever order, incite, assist, or otherwise participate in the persecution of any person because of race, religion, national origin, or political opinion, in association with either the Nazi government of Germany or any organization or government associated or allied with the Nazi government of Germany?
No
Yes
Have you ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in acts involving torture or genocide?
No
Yes
Have you ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in acts involving killing any person?
No
Yes
Have you ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in acts involving intentionally and severely injuring any person?
No
Yes
Have you ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in acts involving engaging in any kind of sexual contact or relations with any person who did not consent or was unable to consent, or was being forced or threatened?
No
Yes
Have you ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in limiting or denying any person's ability to exercise religious beliefs?
No
Yes
Have you ever recruited, enlisted, conscripted, or used any person under 15 years of age to serve in or help an armed force or group?
No
Yes
Have you ever used any person under 15 years of age to take part in hostilities, or to help or provide services to people in combat?
No
Yes
Have you received public assistance in the US from any source, including the US Government or any state, county, city, or municipality other than emergency medical treatment?
No
Yes
Are you likely to receive public assistance in the future in the US from any source, including the US Government or any state, county, city, or municipality other than emergency medical treatment?
No
Yes
Have you ever failed to refused to attend or to remain in attendance at any removal proceeding filed against you on or after April 1, 1997?
No
Yes
Do you believe you had reasonable cause?
No
Yes
Have you ever submitted fraudulent or counterfeit documentation to any US Government official to obtain or attempt to obtain any immigration benefit, including a visa or entry into the US?
No
Yes
Have you ever falsely claimed to be a US citizen in writing or in any other way?
No
Yes
Have you ever been a stowaway on a vessel or aircraft arriving in the US?
No
Yes
Have you ever knowingly encouraged, induced, assisted, abetted, or aided any foreign national to enter or to try to enter the US illegally?
No
Yes
Are you under a final order of civil penalty for violating INA Section 274C for use of fraudulent documents?
No
Yes
Have you ever been excluded, deported, or removed from the US or have you ever departed the US on your own after having been ordered excluded, deported, or removed from the US?
No
Yes
Have you ever entered the US without being inspected and admitted or paroled?
No
Yes
Since April 1, 1997, have you been unlawfully present in the US for more than 180 days but less than a year, and then departed the US?
No
Yes
Since April 1, 1997, have you been unlawfully present in the US for one year or more and then departed the US?
No
Yes
Since April 1, 1997, have you ever reentered or attempted to reenter the US without being inspected and admitted or paroled after having been unlawfully present in the US for more than one year in the aggregate?
No
Yes
Since April 1, 1997, have you ever reentered or attempted to reenter the US without being inspected and admitted or paroled after having been deported, excluded, or removed from the US?
No
Yes
Do you plan to practice polygamy in the US?
No
Yes
Are you accompanying another foreign national who requires your protection or guardianship but who is inadmissible after being certified by a medical officer as being helpless from sickness, physical or mental disability, or infancy, as described in INA Section 232(c)?
No
Yes
Have you ever assisted in detaining, retaining, or withholding custody of a US citizen child outside the US from a US citizen who has been granted custody of the child?
No
Yes
Have you ever voted in violation of any Federal, state, or local constitutional provision, statute, ordinance, or regulation in the US?
No
Yes
Have you ever renounced US citizenship to avoid being taxed by the US?
No
Yes
Have you ever applied for exemption or discharge from training or service in the US armed forces or in the US National Security Training Corps on the ground that you are a foreign national?
No
Yes
Have you ever been relieved or discharged from such training or service on the ground that you are a foreign national?
No
Yes
Have you ever been convicted of desertion from the US armed forces?
No
Yes
Have you ever left or remained outside the US to avoid or evade training or service in the US armed forces in time of war or a period declared by the President to be a national emergency?
No
Yes
What was your nationality or immigration status immediately before you left?
No
Yes
Enter the Information of the Person Submitting This Questionnaire
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