Refusal Questionnaire

INFORMATION ABOUT YOU

Your Current Legal Name

First

Middle

Last

Sex

Date of Birth

Place of Birth (City / State / Country)

Country of Citizenship or Nationality

Phone

Email

Current Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Have you ever been to the United States?

Date of First Entry

Visa Status for First Entry

Place of First Entry (City / State)

Date of Most Recent Entry

Visa Status for Most Recent Entry

Place of Most Recent Entry (City / State)

Have you ever overstayed your authorized period of entry in the US?

Have you ever entered the US without inspection?

How many times?

Have you ever been removed (deported) from the US?

List all time spent in the US and your visa status during each time.

REFUSAL QUESTIONS

Have you ever been charged or convicted of any crime or offense?

Have you ever been refused a visa or entry to the US?

Date of Refused Entry or Visa Refusal

Date Refusal Worksheet was Issued

What questions were you asked during your interview?

From your point of view, what led to your visa or entry refusal?

Enter the Information of the Person Submitting This Questionnaire

Name *

Email *

For Visa and Entry Refusals