3 4 5 9  Lawrenceville - Suwanee  Rd., Suite A,  Suwanee ,  Georgia

Tel: (770) 271-5244 ● Toll Free:  (888) 768-7252 ● Fax: (770) 271-5604 ● Cornel@PotraLawFirm.com ● www.potralawfirm.com

Attorneys:  Cornel Potra – Admitted: Georgia & Washington  ●  Kristina F Potra – Admitted: Georgia

This questionnaire is for the exclusive use of Potra Law Firm.  Please answer all the questions.  Do not leave any questions unanswered.  If you do not have an answer to a question, please insert “N/A”.  It is your responsibility to provide true and accurate information, as well as the evidentiary documents requested

This Document Is For The Attorney’s Office Use Only

 

  

QUESTIONNAIRE FOR I-765

 

Personal Information

 

1. Full Name

a. Family name

 b. First name

c. Middle name

 
 

2. Other name(s) used:

a. Maiden name

b. Name(s) used from prior marriage(s)

 

 

3. Current Address:

a. Street number

b. Apt. number

c. City

d. State

e. Zip Code

 

 

4. Telephone

5. Country of citizenship 

6. Place of birth City/State/Country

7. Date of birth Month/Day/Year

 

8. Gender

9. Marital Status

10. Social Security Number

11. Alien Number

12. I-94 Number

 

13. Have you ever before applied for employment authorization from BCIS?  

      If yes, give the following:

a. The BCIS office you applied with City/State

b. Date of filing Month/Day/Year

 

c. Results

 

 

 

Information about your LAST entry into the U.S.:

14. Date Month/Day/Year

 

15. Location of last entry City/State

16. Manner of last entry (type of visa)

17. Current immigration status (type of visa owned at the moment)

 

 

 

18. BCIS location where you filed the I-485 application (if available):

City/State

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

Documents necessary to file I-765 to the U.S. Department of Homeland Security:

  

*

Copy of the passport

*

 Copy(ies) of the previous Employment Authorization Identification Card(s) (if any)
 

*

A check in the amount of $180.00, the I-765 filing fee

NOTE: THIS DOCUMENT IS THE PRODUCT OF POTRA LAW FIRM. THE USE OF THIS QUESTIONNAIRE BY OTHER INDIVIDUALS OR LAW FIRMS IN ASSISTING OTHERS WITH THE COMPLETION OF DOCUMENTS, OR FOR ANY OTHER PURPOSES, IS STRICTLY PROHIBITED.   POTRA LAW FIRM MAINTAINS ITS COPYRIGHTS OVER THE TRANSLATION OF THIS DOCUMENT.  PERMISSION TO USE THIS DOCUMENT MAY BE OBTAINED ONLY FROM POTRA LAW FIRM.  COPYRIGHT © January 17, 2007