PERSONAL INFORMATION	* Required
Name *
Address
Postal/ZipCode
Country
Email *
Phone
Personal Details:	US Social Security No (if any): Citizen of: Date of Birth: Country of Birth:
What type of immigration assistance are you seeking?

IMMIGRATION HISTORY

Current Immigration Status: Date of First Entry into US: Date Status Expires: Last Entry into U.S.: I-94 Number: Total Entries into U.S.:

OTHER INFORMATION

Have you ever been denied a visa to come to the United States? Yes No

If yes, when and what kind of visa?:

Is there anything, not already covered in this form, that you feel we should know?

STATEMENT OF TRUTHFULNESS

"By submitting this questionnaire, I certify that all of the information contained in this form is true and correct to the best of my knowledge."

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