Number: _____

Irish International Immigrant Center

Immigration Legal Services Intake Form
All information on this form is confidential. It helps us give you the best service possible. It is also used to compile information
required by those who fund our programs. Please follow the instructions and fill in as much information as you can. If you
have any questions, please ask one of the IIIC staff or volunteers.
FOR OFFICE USE
Date:

Legal
Clinic

Office
Appointment

Consult
Call

Email
Inquiry

Repeat Client
Yes No U/K

Staff/Volunteer Name:

A. INFORMATION ABOUT YOU

Last Name

First Name

Street Address

Apt #

Is it OK to send mail and/or email to you?

Preferred Telephone

Home

Cell

Yes

No

Work

What is the best way to contact you?

Phone
Email
Mail
Country of Origin

Middle Name

Gender
M F

Date of Birth

City

State

Zip Code

Is it OK to leave a message on your phone?

Yes

No

Email Address
Marital Status

Single
Married
Divorced
Engaged Separated Widowed

If Ireland, what city/county?

Preferred Language

When did you last enter the U.S.?

Do you have previous entries into the U.S.?

When?

Manner of Last Entry (Type of Visa)

A# (if any)

What is your current immigration status?

Expiration Date

Yes

No

B. INFORMATION ABOUT THE IMMIGRANT, IF A DIFFERENT PERSON THAN ABOVE

Last Name

First Name

Middle Name

Gender
M F

Date of Birth

City

State

Zip Code

Street Address

Apt #

Is it OK to send mail and/or email to him/her? Yes No

Is it OK to leave a message on his/her phone?

Preferred Telephone

Email Address

Home

Cell

Work

What is the best way to contact you?

Phone
Email
Mail

Marital Status

Country of Origin

If Ireland, what city/county?

Yes

No

Single
Married
Divorced
Engaged Separated Widowed
Preferred Language

When did s/he last enter the U.S.?

Does s/he have previous entries into the U.S.? Yes

When?

Manner of Last Entry (Type of Visa or Without Inspection)

A# (if any)

What is his/her current immigration status?

Expiration Date

No

C. YOUR QUESTIONS

Please write your questions here.
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