1. Full Name
2. C urrent
address :
Information about your
current immigrant status in U.S.
Information about your LAST arrival in the
U.S.
16. Full name as it appears on the I-94
17. Place
of last entry City/State
18. Type of visa that granted you access in the U.S.
(if
entered illegally, please state so).
19. Were you inspected by a U.S. Immigration Officer,
when you entered in the U.S.?
YES
NO
Information about your visa
23. Gender
M
F
24. Marital Status
Single
Married
Widowed
Divorced
Seperated
25. Have you ever applied for permanent
resident status in the U.S.?
YES
NO
If yes, please give the following:
26 .
Information about your spouse
27 .
Information about your
children, (if it applies)
If you have more than 10 children,
use the space below.
It is very important that you respect the order of the information requested.
28.
List your present and past membership in or affiliation with
every political organization. If none, please state so
Please answer the following questions with
YES or NO.
1. Have you ever, in or outside the U. S.:
a. knowingly committed any crime of moral turpitude or a
drug-related offense for which you have not
been arrested?
YES
NO
b. been arrested, cited, charged, indicted, fined or
imprisoned for breaking or violating any law or ordinance,
excluding traffic violations?
YES
NO
c. been the beneficiary of a pardon, amnesty,
rehabilitation decree, other act of clemency or similar action?
YES
NO
d. exercised diplomatic immunity to avoid prosecution for
a criminal offense in the U. S.?
YES
NO
2. Have you received public assistance in the U.S.
from any source, including the U.S. government or any state, county, city or municipality (other than emergency medical
treatment), or are you likely to receive public assistance
in the future?
YES
NO
3. Have you ever:
a. within the past ten years been a prostitute or procured
anyone for prostitution, or intend to engage in such activities
in the future?
YES
NO
b. engaged in any unlawful commercialized vice, including,
but not limited to, illegal gambling?
YES
NO
c. knowingly encouraged, induced, assisted, abetted or
aided any alien to try to enter the U.S. illegally?
YES
NO
d. illicitly trafficked in any controlled substance, or
knowingly assisted, abetted or colluded in the illicit trafficking of any controlled substance?
YES
NO
4. Have you ever engaged
in, conspired to engage in, or do you intend to engage in, or
have you ever solicited membership or funds for, or have you
through any means ever assisted or provided any type of material
support to, any person or organization that has ever engaged or
conspired to engage, in sabotage, kidnapping, political
assassination, hijacking or any other form of terrorist
activity?
YES
NO
5. Do you intend to engage in the U.S. in:
a. espionage?
YES
NO
b. any activity a purpose of which is opposition to, or
the control or overthrow of, the government of the United
States, by force, violence or other unlawful means?
YES
NO
c. any activity to violate or evade any law prohibiting
the export from the United States of goods, technology or
sensitive information?
YES
NO
6. Have you ever been a member of, or in any way
affiliated with, the Communist Party or any other totalitarian
party?
YES
NO
7. Did you, during the period from March 23, 1933 to May
8, 1945, in association with either the Nazi Government of
Germany or any organization or government associated or allied
with the Nazi Government of Germany, ever order, incite, assist
or otherwise participate in the persecution of any person
because of race, religion, national origin or political opinion?
YES
NO
8. Have you ever engaged in genocide, or otherwise
ordered, incited, assisted or otherwise participated in the
killing of any person because of race, religion, nationality,
ethnic origin or political opinion?
YES
NO
9. Have you ever been deported from the U.S., or removed
from the U.S. at government expense, excluded within the past
year, or are you now in exclusion or deportation proceedings?
YES
NO
10.Are you under a final order of civil penalty for
violating section 274C of the Immigration and Nationality Act
for use of fraudulent documents or have you, by fraud or willful
misrepresentation of a material fact, ever sought to procure, or
procured, a visa, other documentation, entry into the U.S. or
any immigration benefit?
YES
NO
11. Have you ever left the U.S. to avoid being drafted into
the U.S. Armed Forces?
YES
NO
12. Have you ever been a J nonimmigrant exchange visitor
who was subject to the two-year foreign residence requirement
and not yet complied with that requirement or obtained a waiver?
YES
NO
13. Are you now withholding custody of a U.S. citizen child
outside the U.S. from a person granted custody of the child?
YES
NO
14. Do you plan to practice polygamy in the U.S.?
YES
NO
If your answer is "Yes" to any of the
processing questions above, use the space below to
explain. Please mention the question's number. Answering "Yes" does not necessarily
mean that you are not entitled to adjust your status or register
for permanent residence.
