Initial Intake Questionnaire

INFORMATION ABOUT YOU
Name:
E-mail Address:
Current Address in U.S.:
Last Address Outside of U.S.:
Home Phone:
Work Phone:
Fax Number:
Pager/Cell Phone:
Social Security No:
Citizen of:
Date and Place of Birth:
Passport Information:
What type of immigration assistance are you seeking?
FAMILY INFORMATION
Husband or Wife:
Spouse's Name:
Applying with you?
Children
Total Number of Sons and Daughters:
Parents * Use Mother's Maiden Name
Your Father:
Your Mother*:
Spouse's Father:
Spouse's Mother*:
Previous Marriages
Your's:
 
Spouse's:
 
IMMIGRATION HISTORY
Check every type of immigration status that you have ever held and provide the dates:
Immigration Status
Date(s)
Immigration Status
Date(s)
Check each one that you or your spouse have ever applied for or been the beneficiary of:
 
 
Have you or your spouse ever had any immigration problems? In particular, have you or your spouse ever been under removal, deportation, or exclusion proceedings? Please describe in detail:
EMPLOYMENT HISTORY
Current Employer (or Employer Petitioning on Your Behalf)
 
 
 
 
Employment in Last Five Years (anywhere in the world)
JOB QUALIFICATIONS
List the professional licenses or certifications you possess, from any state or country:
How many years of experience do you have in your position or field?
EDUCATIONAL BACKGROUND
Please list all your education anywhere in the world:
OTHER INFORMATION
During what years, if any, have you filed an Income Tax Return with the IRS?
If you ever had an Employment Authorization Card issued by the INS, give number(s) and validity dates:
Is there anything, not already covered in this form, that you feel we should know?
STATEMENT OF TRUTHFULNESS
"By pressing the Send Questionnaire button below,
I certify that I have read and understood the instructions above this questionnaire.
I certify that all of the information contained in this form is true and correct to the best of my knowledge."