Personal Information

a. Family name

 b. First name

c. Middle name

   a. Street  number

   b. City

   c. State/Province

   d. Zip code

   e. Country

3. Telephone

4. Country of Birth

5. Country of nationality

6. Date of Birth month/day/year

7. Social Security Number (if applicable)

8. Alien Number (A#) (if applicable)

 9. Date of last arrival in the U.S. month/day/year

10. I-94 Number

11. Current  nonimmigrant status (type of visa)

12. Date when status expires month/day/year

a. Are you or any other person included on the application, an applicant for an immigrant visa?   

YES NO

b. Has an immigrant petition ever been filed for you or for any other person included in this application?       

YES NO

 c. Has a form I-485, Application to Register Permanent Residence or Adjust Status, ever been filed by you or    by any other person included in this application?

YES NO

d. Have you, or any other person included in this application, ever been arrested or convicted of any criminal offense since last entering the U.S.?

YES NO

e. Have you, or any other person included in this application, done anything that violated the terms of the nonimmigrant status you now hold?

YES NO

f. Are you, or any other person included in this application, now in removal proceedings?

YES NO

g. Have you, or any other person included in this application, been employed in the U.S. since last admitted or granted an extension or change of status?   If  yes, please give the following:

YES NO